Queensridge Surgery Center Patient Resources

PAYMENT INFORMATION

Please ensure you are on the correct payment site for the company to which you wish to make a payment. Have your statement available, as you will need to enter your account number and payment amount directly from it.

If you have questions regarding your statement for Queensridge Surgery Center (QSC), please contact the billing department at (702) 000-0000 ext. 000.

To make a payment for your QSC statement, CLICK HERE
to proceed.

PAYMENT POLICY

Insurance copayments and deductibles are due at the time of service.
For non-covered procedures or patients without insurance, full payment is required at the time of admission.
We accept the following payment methods: MasterCard, Visa, Discover, American Express, and personal checks.

Please note: You will receive separate bills for your surgeon’s services and the services of the anesthesiologist.

PATIENT FORMS

Click the link(s) below to download the necessary Patient Forms. Once downloaded, fill out the applicable sections, save the document, and email the completed PDF to
info@queensridgesurgery.com. If you have any questions, please contact us at 702-640-0017.

Advance Beneficiary Notice

Patient Grievance Report Form

Advance Directive Form

Accident Questionnaire

Admission and Financial Agreement

HIPPA Form

Medical Records Release Form

Queensridge Surgery Center

10040 Alta Drive, Suite 250 Las Vegas, NV 89145

Phone: 702-640-0017 Fax: 702-331-1159