Patient Forms

General Forms

• File

  Advanced Directives
• File

  Patient Rights and Responsibilities
• File

  Non Discrimination Notice
• File

  Non Discrimination Notice - Spanish
• 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

Florida Transparency Bill

• File

  Financial Policy
• File

  Financial Verification Form

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

Anesthesia Professional Services
4919 Memorial Hwy, Ste 200
Tampa, FL 33632
(877) 603-9578

Reliance Pathology Partners, LLC
5747 Hoover Blvd
Tampa, FL 33634
(813) 490-7213