Patient Forms

General Forms

• File

  Advanced Directives
• File

  Non Discrimination Notice
• File

  Non Discrimination Notice (Spanish)
• File

  Patient Form
• File

  Patient Bill of Rights & Responsibilities
• File

  Patient Bill of Rights & Responsibilities (Spanish)
• File

  Privacy Notice
• File

  Tagline Poster
• File

  Disclosure for Out-of-Network Benefits
• File

  Patient Disclosure of Information
• 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 Verification Form
• File

  Financial Responsibility Acknowledgement
• File

  Financial Policy

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

Medi-Corp, Inc.
25 Commerce Drive, Suite 250
Cranford, NJ  07016
(877) 684-9114

NorthStar Anesthesia
6225 N. State Hwy 161, Ste 200
Irving, TX 75038
(214) 687-0001

PSAP Labs
84 W. Jersey Street, Suite 3
Orlando, FL 32806
(407) 422-1377

BAKO Pathology
6240 Shiloh Road
Alpharetta, GA  30005
(877) 376-7284

Advent Health Fish Memorial
Department of Pathology
1055 Saxon Blvd.
Orange City, FL  32763
(877) 270-5630

Ameripath Pathology
745 Orienta Avenue, Ste 1201
Altamonte Springs, FL  32701
(800) 890-6220