First Name*:
Last Name*:
Age:
Date of Birth*:
Email*:
Address*:
City*:
State*:
Zip*:
Contact Phone*:
Secondary Contact Phone:
Social Security Number:
Driver License Number:
Marital Status:
Occupation:
Employer:
Referring Physician's Name*:
Referring Physician's Phone Number:
Emergency Contact Name:
Emergency Contact Phone:
Name of Primary Insurance*:
Insurance ID #*:
Name of Subscriber*:
Relation to Patient*:
Subscriber's Employer:
Subscriber's Social Security Number:
Subscriber's Date of Birth*:
Subscriber's Work Number:
Name of Primary Insurance:
Insurance ID #:
Name of Subscriber:
Relation to Patient:
Subscriber's Date of Birth:
All fees are payable at the time services are rendered. We accept Visa, Master Card, American Express and Discover Card. Your medical insurance is a contract between you and your insurance carrier and the terms of the contract vary according to the terms of your policy. Final payment for all charges is the patient's responsibility and should it be necessary for this account to be turned over to either an attorney or collection agency for collection, I understand that I will be liable for any charges incurred, including attorney's fees and court costs.
We have elected not to carry Medical Malpractice insurance or otherwise demonstrate financial responsibility.! However, we agree to satisfy any adverse judgments up to the minimum amounts pursuant to S.458.320 (5)(g). F.S.Florida Law imposes penalties against non-insured physicians who fail to satisfy adverse judgments arising from claims of medical malpractice.! This notice is pursuant to Florida Law.
I hereby assign payment directly to South Florida Perinatal Medicine (SFPM) of all benefits applicable and otherwise payable to me from my insurance carrier, HMO or other third party payor, for services rendered by SFPM. I understand that I am financially responsible to SFPM for any and all charges that the carrier declines to pay (including but not limited to: Not a covered benefit; Disallowed by plan). I hereby authorize the release of my medical records as deemed necessary for payment of insurance benefits.
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