Patient Forms

General Forms

• File

  Florida Advance Directive (PDF)
• File

  Notice of Non-Discrimination (PDF)
• File

  Notice Regarding Patient Protections Against Surprise Billing Florida (PDF)
• File

  Right to Receive a Good Faith Estimate of Expected Charges Notice (PDF)
• File

  Language Assistance (PDF)
• File

  Patient Rights (PDF)
• File

  Privacy Notice (PDF)

Florida Transparency Bill

• File

  Financial Policy (PDF)
• File

  Financial Verification Form NOSI (PDF)
• File

  Patient Financial Responsibility Acknowledgement NOSI (PDF)

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

US Anesthesia Partners

851 Trafalgar Court Ste 2003, Maitland, FL 32751

1-888-339-8727

Precision Pathology Lab, a subsidiary of Precision Healthcare Specialists, LLC

6321 Daniels Pkwy Fort Myers, FL 33912

(239) 555-5555

Naples Pathology Associates

1110 Pine Ridge Rd. Unit 306, Naples, FL 34108

(239) 263-1777