If you have any questions concerning the completion of this form, please call 305-663-8413.
Type of Procedure / Treatment / Test
Please select the applicable category below, then select procedure/treatment/test.
On your Admission/Registration day, please bring your prescription, Health Insurance card, other Insurance cards and your Credit Card you may be required to pay a deductible, co-pay, payment or deposit if applicable.
Deposits/Co-payments: Deposits/CO-payments are determined by your insurance company and based on specific plan benefits. For most services, the co-payment will be listed on your insurance card. CO-payments/Patients portions are due at the time of service.