Patient Forms

General Forms

• File

  Non Discrimination Notice
• File

  Non Discrimination Notice (Spanish)
• File

  Your Surgical Experience
• File

  Advanced Directives
• File

  Disclosure for Out-of-Network Benefits
• File

  Patient Disclosure of Information
• 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

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

IPG- Integrated Surgical Solutions
2300 Lakeview Parkway, Suite 500
Alpharetta, GA 30009
(770) 753-0046

Palm Beach Pathology
2013 Ponce De Leon Avenue
West Palm Beach, FL 33407
(561) 659-0770

Labcorp
5610 West LaSalle Street
Tampa, FL 33607
(800) 722-7624

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

APS (Anesthesia Professional Services)
4919 Memorial Highway, Suite 200
Tampa, FL 33634
(866) 631-7890