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