Forms

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Forms

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Want to Speed Up the Process?

Complete these forms & bring them to your visit along with:

 

1.  Current Insurance Card.

2.  A Complete List of your Medications.

3.  Records from your other Doctors.

4.  Recent Hospital, ER Visits.

5.  Labs & Test Results from the last 12 months.

 

 Click on the appropriate forms, below,  complete  & bring them to your visit.

1.  New Patient Forms

2.  Established Patient Annual Visit Form

3.  Notice of Privacy Practices ( to be completed by EVERY New patient )

4.  Medicare ABN Form (to be signed every year by every Medicare patient)

5.  Medical Record Release Form (Use this form in advance of your visit to request: Office, Hospital Records, LAB & Test Results. You may make multiple copies as needed. Mail or fax completed forms to your providers and bring copies with you to your appointment.)

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Our Office:
7401 N UNIVERSITY DR STE 101
TAMARAC, FL, 33321
PHONE:  (954) 722-2002
FAX: (954) 722-2041

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Office Hours:
Monday-Thursday: 9am-5pm
Friday: 9am-12pm

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