Office Policies

  • Financial Policy

    This is an agreement between Medi-Partners of South Florida, and Medi-Station, as the creditor, and the name of the Patient / Guarantor on this form. By executing this agreement, you agree to pay for all services that are received.

    Payment options if you have no Insurance or insurance company we DO NOT accept payment:
    on the day when treatment is rendered.
  • Payment options if you have no Insurance:
    You are responsible for paying your co payment, deductible, and any disbursement portion at the time services are rendered in
    You are responsible for any coinsurance or amount stated per your insurance explanation of benefits. If we can not verify your insurance, we will ask you to pay the contracted insurance fee and contact the office when the explanation of benefits is received to see if you are due a refund.
  • Insurance: Insurance is a contract between you and your insurance company. We are not part of that contract, in most cases. We will only bill your primary and secondary insurance. Although we can estimate what your insurance company can afford, it is the insurance company that makes the final determination of your eligibility. You agree to pay any part of the expenses not covered by the insurance. We are not a Medicaid provider; We can not send billing to the Department of Employment and Family Services on your behalf. If you are a Medicaid beneficiary, you will be financially responsible for your services today.

    Workers Compensation: We require that you inform us at the time of the visit that this is due to a situation related to the work. Otherwise, you will be financially responsible for this bill. If your claim is rejected, you will be responsible for the payment in full.

    EXTERNAL LABORATORY SERVICES: If you need a larger laboratory job, some tests can not be covered by your insurance company. In that case, you may receive an invoice / additional statement for these services from the external lab. Medi-Station will do everything possible to inform you of the pre-test expenses.
  • Date Format: MM slash DD slash YYYY
  • Notice of Privacy Practices: I have been presented with a copy of the Notice of Privacy Practices, detailing how my health information may be used and disclosed as permitted by federal and state laws and outline my rights regarding my health information. If you have any questions about Medi-Station's notice of privacy practices, you may contact the Medi-Station Privacy Officer at 305-603-7650.
  • Date Format: MM slash DD slash YYYY
  • Medical Record Release


    I,
  • authorize the release of my medical record information to my primary care physician. I understand that this authorization may be revoked at any time.
  • Date Format: MM slash DD slash YYYY
  • Medical Release for a Minor Child:


    I,
  • , Parent or Legal Guardian of
  • (Name of Minor Child), hereby authorize Medi-Station to perform any medical or surgical treatment which my be necessary for the well being of the above mentioned minor. I agree to keep Medi-Station and the physician harmless for rendering such care.
  • Date Format: MM slash DD slash YYYY
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