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Patient Information

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Insurance Information

Assignment and Release of Benefits

I hereby assign all medical and/or surgical benefits, to include Major Medical Benefits to which I am entitled, including Medicare, private insurance, and any other health plan to: Eric D. Weston, MD.

This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release medical information to secure payment.

ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call 1-727-298-0802.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüistica. Llame al 1-727-298-0802.

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-727-298-0802.

Financial Policy of Eric D. Weston, MD

Thank your for choosing Eric D. Weston, MD as your gastroenterologist.

We are committed to providing you with the best possible medical care, and we are available to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our relationship. Your assistance in complying with our payment policies will help control our overhead expenses, thereby keeping medical fees at a reasonable cost.

If you cannot keep an appointment, please give us at least one day's notice. That way we can schedule another patient to see the doctor.

Full payment or co-payment is due at the time of service. We accept cash, check, Visa, MasterCard, Discover or American Express.

There will be a $25.00 service charge for any returned check.

Our office will file primary and secondary insurance for Medicare, managed care plans (HMO/PPO), and other commercial insurance plans with which we are contracted. If we accept your insurance, you must pay any co-payment at the time of service. If you are scheduled for a procedure and you have an unmet deductible, we will collect a deposit when we schedule your procedure. Any amount indicated as patient responsibility by your insurance company is due within 30 days.

As all insurance plans have specific rules and regulations regarding the use of certain labs and treatment centers, as well as referrals to specialists, we ask that you be aware of your plans directives and inform the doctors of them so that they can try as much as possible to keep within the scope of your plan, especially if the need arises at night or over the weekend.

Please notify our office immediately when you change medical insurance, home address or telephone numbers.

Bring your current insurance card every time you visit our office. It contains valuable information regarding coverage and benefits. If your insurance care has not been issued to you by the time of your visit you will be treated as a self-pay patient. Payment will be expected at the time of the visit and the claim will be submitted for you when you receive your card.

I have read and I agree to the terms of this financial policy.

Thank you for understanding our financial policy. Please let us know if you have any questions or concerns.

Uses and Disclosures of Your Protected Health Informationn (PHI)

I understand that as part of my healthcare, the practice originates and maintains paper and/or electronic records describing my health history, symptoms, examination, test results, diagnoses, treatment and any plans for future care or treatment. I understand that this information serves as:

  • A basis for planning my care and treatment
  • A means of communication among the health professionals who contribute to my care, such as referrals.
  • A source information for applying my diagnosis and treatment information to my bill
  • A means by which a third-party payer can verify that services billed were actually rendered
  • A tool for routine health care operation, such as assessing quality, and reviewing the competence of staff

I have been provided with a "Notice of Patient Privacy Practices" that provides a more complete description of information uses and disclosures.

Tell us with whom we may discuss your protected health information: (Name and relation - Example: Jane Doe, Wife; Jan Doe, daughter)

Messages or Appointment Reminders

Messages will be non-sensitive nature, such as appointment reminders.

I understand that as part of treatment, payment or health care operations, it may become necessary to disclose health information to another entity, e.g. referrals to other healthcare providers. I understand that my information may be used or disclosed, without an authorization, as permitted or required by law.

ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call 1-727-298-0802.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüistica. Llame al 1-727-298-0802.

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-727-298-0802.

I agree to assign insurance benefits to Eric D. Weston, MD, I acknowledge full financial responsibility for services rendered by Eric D. Weston, MD and authorize transfer of all unpaid amounts to me, which Includes, but is not limited to, Co-pays. Deductibles, Co-Insurance. Pre-existing Clauses. excluded conditions and/or termination of coverage. I agree to pay allle9al fees including attorney and court fees as well as collection costs in the event of default payment of charges that are my financial responsibility. I further authorize all insurance payments to be made directly to Eric D. Weston. MD. Payment Is expected at the time of service. We bill all insurance companies that we are contracted with as "network" providers as a courtesy to our patients. We will file your Insurance as a courtesy to you. If your deductible has not been met and/ or you are responsible for a co-payment under your plan, we will expect the payment of such upon delivery of services at the time of your visit. If you are scheduled for a procedure and you have an unmet deductible, we will collect a deposit when we schedule your procedure There will be a 525.00 fee for returned checks.

We are committed to ensuring your Protected Health Information (PHI) remains confidential. Your paper and electronic medical records are safeguarded and released only with your consent, or to your insurance carrier, other medical professionals directly involved with your care, or as required by law. Our Notice of Privacy Practices policy manual, which explains how your medical Information may be used and disclosed. is available for your review or you are welcome to have a copy. If you would like to release your PHI to another doctor or facility you will be required to fill out a separate form to request your records.

The undersigned consents to the medical care and treatment, as may be deemed necessary or advisable in the judgment of Eric D. Weston, MO or other providers, which may include but are not limited to laboratory procedures, X-ray examination, medical or surgical treatment or procedures. anesthesia or other services rendered to the patient under the general and special instructions of the patient's physician. Eric D. Weston, MD has the right to refuse to treat you If you refuse to sign this consent or if you choose to revoke this consent.

I agree that the facility, Eric D. Weston, MO or any other collection or servicing agency or agencies retained by the facility (together referred to hereafter as "collectors) to collect "any money that I owe to the facility may contact me by telephone or text message at any number given by me or otherwise associated with my account. including but not limited to, cellular/wireless telephone numbers which may result in my incurring fees for the call or text message. I understand, acknowledge and agree that the collectors may contact me by automatic dialing devices and through pre-recorded messages, artificial voice messages or voice mail messages. I further agree that the collectors may contact me using e-mail at any e-mail address I provide to the facility or otherwise associated With my account.

Patients are required to show both proofs of insurance and a Government-issued photo ID at their initial and all subsequent visits. The patient (parent/legal guardian) is responsible for informing our office of any changes in your insurance coverage since your last visit. Please assure that notification is made no later than 24 hours prior to your appointment to avoid having to reschedule your appointment.

Please give all forms regarding disability to the nursing staff. Please do not give these forms to the physician. You will need to expect 72 hours for these forms to be completed. Fill out the portion of the disability form that is for the patient and leave the physician's area blank.

We must be notified 24 hours in advance of an office appointment cancellation/need to reschedule. For a procedure cancellation! reschedule (colonoscopy or EGO). we must be notified at least 48 hours In advance of the procedure date.

Eric D. Weston, MO has an ownership interest in Clearwater Endoscopy Center. He created the center due to his commitment to providing Quality healthcare services to his patients at a reasonable cost. You have the right to choose where to receive services, including an entity in which your physician may have a financial relationship. Or. Weston may also provide endoscopic services at Morton Plant Hospital, 323 Jeffords St., Clearwater, FL 33756, (727) 462-7745.

I authorize Eric D. Weston, MD, and its affiliated providers to view my external prescription history via the RxHub service. I understand that prescription history from multiple unaffiliated medical providers, Insurance companies, and pharmacy benefit managers may be viewable by my providers and staff here. and it may include prescriptions back in time for several years. My initials and signature certify that I read and understood the scope of my consent and that I authorize the access.


  • I acknowledge that I have received access to the "Notice of Privacy Practices" for Eric D. Weston, MD. I have read and understand the "HIPAA & Release of Medical Information Policy".
  • I hereby authorize Eric D. Weston, MD to release any information requested by the insurance company or companies or respective representatives and act as my agent to secure payment for any and all services rendered.
  • I understand that I am financially responsible to the physician for any and all charges incurred by myself and/or dependents.
  • I have read and understand the "Consent for Treatment" and "Disclosure of Financial interest".
  • I further acknowledge and understand that I accept the terms outlined in each of the policies.

Consent to Share My Health Information With the BayCare Electronic Health Exchange

The BayCare EIectronic Health Exchange (B.yCare eHX) is an exciting program designed to improve your health care and make office visits easier and more convenient. This authorization will allow all of your doctors participating in the BayCare eHX to enroll you in the BayCare eHX and to disclose your demographic, insurance and medical information(collectively, your "Health Information") to the BayCare eHX so that It can be shared with other providers or health care, including doctors, nurses, health professionals. hospitals and other health care facilities. Only healthcare providers and authorized personnel that participate in the BayCare eHX, and others whose job it Is to maintain, secure, monitor and evaluate the operation of the BayCare eHX. will be able to access your health information. The BayCare eHX will allow your provider access to your health information more quickly and accurately than with paper charts.

You may use this consent form to decide whether or not to allow the BayCare eHX to see and obtain access to your health information in this way. You can give consent or deny consent, and this form may be filled out now or at a later date. Your choice will not affect your ability to get medical care or health insurance coverage. Your choice to give or to deny consent may not be the basis for denial of health services. However, to the extent you have denied consent, you understand that your health information will not be available to other providers on the BayCare eHX for your medical treatment.

If you check the "I GIVE CONSENT" box below, you are saying "yes, members of the BayCare eHX may see and get access to all of my health information through BayCare eHX for any purpose."

If you check the "I DENY CONSENT" box below, you are saying "No, members of the BayCare eHX may not be given access to my health information through the BayCare eHX for any purpose."

Please carefully read the Information on the back of this form before making your decision.


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