Patient First name_______________________
Patient Last name_______________________
Patient Phone__________________________
Date of Service_________________________
(Circle Location of Service) AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMof serviceinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Physician/Specialist Name(If known)_________________________
Do you have health insurance? Yes No
Description of service or procedure or current procedure terminology(CPT) code_____________________
Inpatient or Outpatient: Inpatient Outpatient
Requestor Information (if not patient)_______________________
Requestor First name____________________________________
Requestor Last name____________________________________
Requestor Phone number________________________________
Today's date_____________________
Print and "Submit" to : Seven Springs Surgery Center, 2024 Seven Springs Blvd, New Port Richey, Fl 34655 .
On "Submit" you confirm that you understand the following statements.
Any information received is only an estimate. The estimated price will be based on information you and your provider share with us about what services are expected to be performed. Many factors will influence the actual amount you will be billed, including whether the provider finds it necessary to perform more, fewer or different procedures than originally expected at the time of service.
Any information received reflects only hospital charges. It does not include charges for services provided by the physician, surgeon, anesthesiologist, emergency room physician or other providers.
If you are insured, prior to your visit, it is important you contact your insurance company to ensure that services required are "covered services." In the event that they are not covered services under your plan, please refer back to our uninsured information
Current Procedure Terminology(CPT) Code - A CPT code communicates to payers what medical and surgical procedures and diagnostic services are rendered by your provider and where payment is expected. You can find on the order from your doctor.
