New Patient Enrollment Form

NEW PATIENT ONLINE FORM
Please fill the information below before coming to your appointment

We are located at:
5651 49th St. N, Saint Petersburg, FL 33709

IMPORTANT REMINDER!

THESE FORMS MUST BE FILLED OUT 48 HOURS PRIOR TO YOUR APPOINTMENT.
FAILURE TO DO SO, WILL CAUSE YOUR APPOINTMENT TO BE RESCHEDULED.
DEAR VALUED PATIENT

We know that as a patient you have many options for your Gastroenterology and Liver Disease Management Care, and we thank you for choosing our practice to help you with your continued care. We strive to provide high quality care in a professional and ethical manner.

Please complete the following web form. If you have questions or need assistance, please let us know. Once you finish and submit this form, we will receive an encrypted and secure copy of your inputs, this way we make sure your PHI (Protected Health Information) is protected from any kind of threat and you are able to be seen in a timely manner, skipping the manual process of filling paperwork at the office. You are also able to upload digital copies of your Photo ID, insurance card(s) and other documents of your own choice, if you do not have any digital copies, please bring them to your appointment. If we do not have your Photo ID and insurance card(s) the day of your appointment, you will be rescheduled. Co-pay is due at the time of service.

Patients arriving later than 15 minutes past their expected arrival time will be considered late and may be asked to reschedule.

We will contact you by phone with your lab/test results, if necessary, within a reasonable time frame. If you have not heard from us within 10-14 days, please contact our office.
FINANCIAL POLICY

It is the patient’s responsibility to verify coverage for our facilities. Should your insurance change after you have scheduled your appointment, please contact our office at (727) 443-4299, Option 2.

Our practice accepts most insurances. Please check with your insurance company to verify your coverage, co-pay, deductible and co-insurance fees. Patients are responsible for all services not covered by your healthcare insurance. Please advise our office whenever you have a change of address, phone number or insurance coverage.

Patients who fail to keep up with their appointments or do not notify the office or facility of cancellation or reschedule 72 hours prior, will be assessed a no-show fee of
- $50 for office visits at Florida Digestive Specialists
- $100 for Bay Area Endoscopy and Surgery Center procedures
- $150 for procedures at the hospital.
This must be paid in full prior to your next appointment. If a patient misses three (3) appointments without contacting us 72 hours prior to appointment time, you will be discharged from the practice.

For patients that might require processing FMLA paperwork, Florida Digestive Specialists charges a $25 flat fee for the service.

The undersigned agrees, whether as a patient or an agent, that in consideration of services to be rendered, that patients is obligated to pay account with Florida Digestive Specialists in accordance with the regular rates and terms of Florida Digestive Specialists. Should the account be referred to an outside agency or attorney for collections, the undersigned agrees to pay reasonable collection and attorney fees for collection expenses.

I authorize Florida Digestive Specialists, its assignees, and third-party collection agents to use any contact information I have provided to communicate regarding my account. I understand and agree that any of these entities may contact me by manual dialing or by using an automatic telephone dialing system, and they may use an artificial or pre-recorded voice. I understand that these calls may be to my home phone, business phone, cellular phone, or other wireless device, and I consent to such calls regardless of whether I incur charges as a result. I also agree to receive text messages on my cellular device and e-mails sent to any e-mail address I may provide. I understand that any consent provided hereunder may be revoked by me at any time, by informing Florida Digestive Specialists, its assignees, and/or third-party collection agents of such revocation of consent.
Name *

First Name Middle Initial Last Name
Date of Birth *

Month Day Year
Date
Signature *

Clear
Date

{name475}
CONSENT TO TREATMENT
I, the undersigned, acting on my behalf or as the legally authorized representative of the patient hereby consent to examination, diagnostic testing and treatment by Florida Digestive Specialists (FDS), and its employees. I acknowledge that no guarantees have been made to me regarding the results of any examination, care or treatment provided by Florida Digestive Specialists.
COMMUNICATIONS CONSENT
I authorize Florida Digestive Specialists to leave telephone messages for the patient, that may contain medical information at the following number: *
Please enter a valid phone number. Only numbers, no symbols.
I authorize Florida Digestive Specialists to contact the patient at the following e-mail address:
example@example.com

I authorize Florida Digestive Specialists to share the patient's medical information with:

	Name	Relationship
1st Contact
2nd Contact
3rd Contact
4th Contact

RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS
I hereby authorize the release of my medical information, including Protected Health Information (PHI) concerning my treatment to any third-party payor, inclunding but not limited to health plans and insurers, Medicare, Medicaid, TRICARE and CHAMPVA for payment purposes. Further, I authorize payment of any insurance or other benefits that may be made on my behalf by any party, including any health plan or insurer, Medicare, Medicaid and any other federal or state healthcare programs, directly to Florida Digestive Specialists. I understand that this assignment of benefits does not relieve me of my obligation to pay Florida Digestive Specialists for any charges not covered by this assignment or not paid by insurance or healthcare benefits.

I understand and agree, whether I sign as agent or patient, that I am responsible for and guarantee payment of any charges incurred for the services provided to the patient by Florida Digestive Specialists. I further understand and agree that I will be responsible for payment of any deductible, co-payment, co-insurance amounts, or any charge that is not covered or paid by insurance, healthcare benefits or third-party payors.

I authorize Florida Digestive Specialists to release the patient's medical information, including HIV testing and treatment information, to other parties (which may include include providers, payors, business associates or other entities) for the purpose of treatment, payment or healthcare operations.

I authorize Florida Digestive Specialists to retrieve and obtain my Protected Health Information from any past provider's office, institution or facility for the purpose of the continuation of medical treatment.
ACKNOWLEDGEMENT
By signing this form, I agree with and accept the aformentioned consents, terms and agreements.
Signature *

Clear
Date *

{name475}
DOCUMENT UPLOAD
If you have any digital copies of any documentation, insurance card, driver's license, etc., please upload them here. This form is encrypted, secure and HIPAA compliant, so your Protected Health Information is safe.
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