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Florida Orthopaedic Institute Surgery Center
813-972-4905
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Patient Forms

Please find the attached forms for your review. If you have any questions regarding the forms and/or their content, please feel free to contact us at 813-972-4905, option 3, then option 5. This information will be again reviewed with the patient on the day of the surgical procedure.

Forms

  1. Advance Directives
  2. Assignment of Benefits
  3. Designated Individuals Authorization
  4. HIPAA Consent Form
  5. Notice of Disclosure of Financial Interest for the FOIASC
  6. Patient Bill of Rights
  7. Medical Records Release
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    • Financial Disclosure Notice
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    • Transparency in Healthcare
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Copyright 2023 Florida Orthopaedic Institute Surgery Center. All Rights Reserved

Pursuant to s.408.05, F.S., for information about quality measures, statistics and data as disseminated by AHCA, please click on the following link: Florida Agency for Health Care Administration.

  • Home
  • Surgery
    • Anesthesia
    • Neuromonitoring
  • Patient Information
    • Patient Forms
    • Insurance
    • Bill Pay
    • Financial Information
    • Financial Assistance
    • Financial Disclosure Notice
    • Affordable Care Act
    • Collection Procedures Policy
    • Refund Policy
    • Patient Rights
    • Patient Satisfaction
    • Transparency in Healthcare
    • Links
  • About
    • Careers
    • Executives
  • Locations
    • Surgery Center – Telecom
    • Surgery Center – Citrus Park
  • Contact Us