Notice of Disclosure of Ownership Interest

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Notice of Disclosure of Ownership Interest

Surgical Specialists, ASC is a partnership between HCA Fort Walton-Destin Hospital and local physicians, one of whom may be your physician. These physicians have become owners as a result of their commitment to quality healthcare and service to their patients.

Under current Florida law, a physician-owned facility may not provide items or services to a patient unless the patient signs a written notice disclosing certain matters. Please be advised:

· Surgical Specialists, ASC may have a financial relationship with your physician as indicated above.

· You have the right to choose where to receive services; including an entity in which your physician may have a financial relationship.

· Three reasonable alternative sources of services available are:

1. HCA Fort Walton-Destin Hospital

2. Ascension Sacred Heart Emerald Coast Hospital

3. HCA Twin Cities Hospital