• JOHN W GRACE, M.D. INTAKE FORM

    NOTE: DUE TO RECENT INCREASED DEMAND AND DRAMATIC CHANGES TO PRACTICE FROM COVID WE ARE UNABLE TO ASSIST ALL PROSPECTIVE PATIENTS. THERE MAY BE A 1-2 WEEK DELAY IN RESPONDING TO THIS FORM AT THIS TIME. IF YOU HAVE NOT HEARD FROM US WITHIN 2 WEEKS PLEASE CALL THE OFFICE AT 352-601-0422. IF YOU ARE HAVING A MENTAL HEALTH EMERGENCY CALL 911 OR PRESENT TO THE NEAREST EMERGENCY ROOM. IF A REQUIRED CATEGORY DOES NOT APPLY TO YOU TYPE: "N/A"

  • NOTE
    AFTER REVIEWING SUBMITTED PAPERWORK, WE MAY NOT BE ABLE TO ACCEPT YOU AS A PATIENT AT THIS TIME


    THERE ARE MANY POSSIBLE REASONS THAT WE CANNOT DISCUSS (PRIVACY ISSUES, CONFLICT OF INTEREST, ETC).

    THEREFORE, POTENTIAL PATIENTS WILL BE INFORMED OF NON-ACCEPTANCE VIA RECEIVING THE FOLLOWING FORM LETTER ON OUR WEBSITE.

     


    THEY MAY ALSO CHOOSE TO RECEIVE THE FOLLOWING VOICE MAIL:

    "Hello, this is John W. Grace, M.D.,P.A. we are unable to accept you as a patient at this time.  Your paperwork will be kept on file and you may call the office in six months to see if we are able to assist you at that point.  Other opportunities for care are listed on our website.”

     


    HOW WOULD YOU PREFER TO BE NOTIFIED IF WE ARE UNABLE TO ASSIST YOU AT THIS TIME?

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  • BY SIGNING AND DATING BELOW I AGREE THAT I HAVE READ, FAMILARIZED AND WILL ATTEMPT TO FOLLOW THE POLICIES AND GENERAL INSTRUCTIONS OF JOHN W GRACE, MD PA AS POSTED ON THEIR WEBSITE AT: https://www.johnwgracemdpa.com/instructions-policies

  • Please understand that verification of insurance and benefits can delay the scheduling of your first appointment.   If you would prefer, you may pay the self-pay rate ($275 first eval) and ($100 follow ups) while your benefits are determined, understanding that you will be credited and reimbursed for any payments received by insurance.  If so please click the appropriate box below.  

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