Patient Forms
Please select a button below to view, download, or print the selected form.
Accepted Insurance Plans
Accepted Insurances
As a courtesy, our billing office will file claims with all insurance carriers that we are contracted with (please refer to the list below). If you have questions regarding your specific insurance benefits we urge you to contact the member services number listed on the back of your insurance card.
| Aetna | Medica |
| AvMed | Medicare |
| Blue Cross Blue Shield | Positive Healthcare Plans (PHP) |
| Care Plus Health | Preferred Care Partners |
| Cigna | Total Care Administrators / Best Choice |
| Humana | United Healthcare |
Referrals
As a specialist, some insurance companies (particularly HMO’s and TRI-CARE) require that prior to any visit you must obtain an authorization or referral from your primary care physician. It is the patients responsibility to know if this is required by your insurance and, if so, to ensure that a valid referral is on file with our office at the time that your appointment is scheduled. Please work with your primary care physician and insurance carrier to obtain a valid referral prior to requesting an appointment.
Out-of-Network Commercial Insurance
If we are not contracted (out of network) with your insurance company we will not be able to bill your insurance carrier for your visit. You will be considered a self-pay patient and payment for services rendered will be due at the time of your appointment. If requested, we will provide you an itemized encounter form that includes the information that is necessary for you to file your claim directly with your insurance carrier.
Self Pay Patients
In order to simplify the out-of-pocket costs for self-paying patients, our office has established a flat fee that includes the office visit and any office procedure(s) that are performed at the time of your appointment. Our self-pay rates are as follows:
New Patient: $150 (includes any office procedures performed)
Established Patient: $125 (includes any office procedures performed)
We accept Visa, MasterCard, American Express and Cash as forms of payment.
Medical Record Request
If you would like to request a copy of your medical records please complete the form below and fax it to our office at (954) 938-1899.
Please note that the fee for reproducing medical records is as follows (Florida Rule 64B8-10.003):
Fees: $1.00 per page for the first 25 pages, 25¢ per page for each additional page.