Patient Forms

General Forms & Information

• File

  Non Discrimination Notice
• File

  Non Discrimination Notice (Spanish)
• File

  Advanced Directives
• File

  Patient Disclosure of Information
• File

  Disclosure for Out-of-Network Benefits
• File

  Patient Bill of Rights
• File

  Pre-Anesthesia Assessment
• File

  Right to Receive a Good Faith Estimate of Expected Charges
• File

  Notice Regarding Patient Protections Against Surprise Billing

Florida Transparency Bill

• File

  Financial Policy
• File

  Financial Verification Form
• File

  Price Transparency Act - Addendum

Services may be provided by other healthcare providers who may bill separately.

Labcorp
5610 West LaSalle Street,
Tampa, FL 33607
(305) 436-9232

Quest
4225 East Fowler Ave.
Tampa, FL 33617
(866) 697-8378

Vitro Molecular Laboratories
8700 West Flagler, Suite 100
Miami, FL 33174
(305) 267-7979

East Coast Anesthesia
401 SW 42nd, Suite 201
Miami, FL 33134
(866) 223-9156