We have provided some of the patient forms you may need for your surgical center appointment for reference. Forms can also be completed inside your account on One Medical Passport.
Pre-Admission Forms
- Patient Registration
- Medical Reconciliation
- Pain Diagram
- Patient History Questionnaire
- Patient Rights and Responsibilities (English)
- Patient Rights and Responsibilities (Spanish)
- General Consent
- Insurance Appeal Payment Agreement
- DISC Policy on Advanced Directives (Spanish)
- Release of Medical Information
Policies
- Privacy Notice
- Our Ethics, Rights, and Responsibilities
- California Advanced Directive Policy
- Florida Advanced Directive Policy
- Grievance Policy
- Service Animal Policy
- Florida Health Finder
- Service Bundle Estimates
- Good Faith Estimates
- Financial Assistance / Charity Care
- No Surprises Act & Billing Protections
- Ownership Disclosure
- Non-Discrimination & Language Assistance
- Clinical Scope Overview
- Accreditation & Licensing
- Preparing For Surgery Guide
- After Surgery Guide
- Notice to Patients
Notice To Consumer
All physicians and vendors providing services at this Ambulatory Surgical Center (ASC) are independent practitioners and are not employees or agents of the Ambulatory Surgical Center.
Notice to California Patients
Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint go to www.mbc.ca.gov, email: licensecheck@mbc.ca.gov, or call (800) 633-2322
Notice to Florida Patients
Medical doctors practicing in the state of Florida are licensed and regulated by the Florida Board of Medicine. To verify a physician’s license status, credentials, or to file a complaint regarding a physician’s professional conduct in Florida, patients may contact the Florida Board of Medicine:
Florida Board of Medicine
Department of Health – Board of Medicine
4052 Bald Cypress Way, Bin C-03
Tallahassee, FL 32399-3253
Phone: (850) 245-4131 (Board Office)
Online License Verification & Complaints: https://flhealthsource.gov (use the Medical Quality Assurance (MQA) Search Services portal)