Patient Information

Insurance Information

Primary

Secondary Insurance (If applicable)

PLEASE GIVE INSURANCE CARD(S) TO FRONT DESK FOR COPYING- THANK YOU

FINANCIAL AGREEMENT

I understand that I’m directly responsible for all the charges incurred for medical service for myself and my dependents regardless of insurance coverage. I authorize treatment of the person named above and agree to pay all fees and charges for such treatment. I agree to pay all charges for me and members of my family shown by statements. Charges shown by statements are agreed to be correct and reasonable unless protested in writing within 30 days of the billing date. I furthermore agree to pay legal interest, collection expense, and attorneys’ fees incurred to collect any amount I owe.

It is agreed that payments will not be delayed or withheld because of any insurance coverage or the pendency of claims thereon, and all proceeds of insurance are assigned to this office where applicable. AGREEMENT: This above information is for the purpose of obtaining credit and is warranted to be true. CANCELATION POLICY: If you have any inconvenience for showing to your appointment please call us at least 24 hours before your appointment, in order to reschedule it. Our No-Show fee will be $50, and it has to be paid before your next appointment.

RETURNED CHECKS: Your account will be charged $30 fee for each returned check.

AKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

By signing this form you aknowledge receipt of the Notice of Privacy Practices for Gulf View General Surgery,LLC . Our Notice of Privacy Practice provides information about how we may use and disclose your protected information. We encourage you to read it in full. Our Notice of Privacy Practices is subject to change.

AKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

By signing this form you aknowledge receipt of the Notice of Privacy Practices for Gulf View General Surgery,LLC . Our Notice of Privacy Practice provides information about how we may use and disclose your protected information. We encourage you to read it in full. Our Notice of Privacy Practices is subject to change.

Call us today for an appointment - (239) 260-1115

We accept all major insurance companies. We know that the sooner treatment is started, the better. That is why we will work with all new patients to see them promptly.

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