Patient Forms

General Forms

• File

  Florida Advance Directive (PDF)
• File

  ASC Brownwood Notice of Privacy Practices (PDF)
• File

  Non-discrimination Notice (PDF)
• File

  Aviso de no discriminación – Español (PDF)
• File

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

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

  Patient Rights (PDF)
• File

  Pediatric Patient Rights and Responsibilities (PDF)
• File

  Language Assistance (PDF)

Florida Transparency Bill

• File

  Financial Policy (PDF)
• File

  Financial Verification Form (PDF)
• File

  Patient Financial Responsibility Acknowledgement Form (PDF)

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

Labcorp
2955 Brownwood Blvd, Ste 110
The Villages, FL 32163
(352) 399-4638

American Ambulance
4601 North John Young Parkway
Orlando, FL 32804
(407) 822-3700

Informed Diagnostics
1111 Freeport Pkwy
Coppell, TX 75019
(866) 588-3280

Anesthesia Dynamics
220 N Street NW Suite 152
Washington, DC 20007
(800) 959-5509