Forms

General Forms

• File

  Non Discrimination Notice
• File

  Non Discrimination Notice - Spanish
• File

  Advanced Directives
• File

  Interpreter Languages
• File

  Florida Top 15 Taglines
• File

  Disclosure for Out-of-Network Benefits
• File

  Patient Disclosure of Information
• File

  Pre-Anesthesia Assessment
• File

  Right to Receive a Good Faith Estimate of Expected Charges
• File

  Notice Regarding Patient Protections Against Surprise Billing
• File

  Patient Privacy Notice - Spanish
• File

  Patient Privacy Notice - English

Florida Transparency Bill

• File

  Financial Policy
• File

  Financial Verification Form

Services may be provided by other healthcare providers who may bill separately.

US Anesthesia Partners

851 Trafalgar Court

Suite 200E

Mainland, FL 32751

Privacy Notice and Patient Rights

• File

  Privacy Notice
• File

  Patient Bill of Rights

Ownership

• File

  Disclosure of Ownership

Patient Forms

• File

  Pre-procedure Information