CONSENT TO TREAT - ACKNOWLEDGEMENT OF BENEFITS
Consent for Medical Treatment
I/We voluntarily consent to medical treatment and diagnostic procedures provided by HEART CARE CENTER OF FLORIDA and its associated physicians, clinicians and other personnel. I/We consent to the testing for infectious diseases such as, but not limited to AIDS, Hepatitis and drug testing if deemed advisable by the physician. I/We am/are aware that the practice of medicine and surgery is not an exact science and I/We acknowledge that no guarantees have been made as to the result of treatments or examinations.
Assignment of Insurance Benefits
I/We guarantee payment of all charges made for or on account of the patient and I/We assign our rights to any insurance benefits or other funding to the physician and HEART CARE CENTER OF FLORIDA. I/We understand that I/we HEART CARE CENTER OF FLORIDA can obtain my/our credit report for review in collection of this in the event that my/our account is placed with collection agency or attorney for collection or collected. I/We shall pay all collections fees and costs, including reasonable attorney fees for Medicare beneficiaries. I/We have provided all necessary information for proper assignment of Medicare benefits.
"No Show" Policy
As a courtesy to staff and patients, please call the office upon becoming aware of potential conflicts with your scheduled appointment time.
PLEASE PROVIDE AT LEAST 24 HOUR NOTICE OF ANY CANCELLATION OR RESCHEDULING OF APPOINTMENT. This reserves the right to charge a $50.00 administrative fee for any non-emergent cancellation that is not made within 24 hours of your scheduled appointment.
There is a $20.00 fee for completion of disability forms, Life insurance, or Workmen's Compensation forms. Payment shall be made at the time of the form being dropped off. Please allow 10 business days for forms completion. Forms cannot be completed prior to your office visit or surgery date. We understand the importance of the completion of your forms. Be certain to provide any and all necessary information to insure that your paperwork is properly accurately.
I have read the above Consent to Treat, and Acknowledgement of Benefits. I have also read Heart Care Centers of Florida "No Show" Policy, and am aware that failure to show for scheduled appointment or provide at least 24 hour's notice of will result in $50.00 fee.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.