Face Sheet Form

Fill up this form to provide us with your basic information. This information will be used for your insurance company and any other appropriate agency as required for claims payment.

Upload Your Forms

Send your documents online to St Pete and we will process them immediately.
Rename the file to YOUR_NAME-form.doc and select upload.


FACE SHEET FORM

The above information is true to the best of my knowledge.
By sending this form, I agree to the following:

  • I authorize the release of information to my insurance company and any other appropriate agency as required for claims payment.
  • I authorize my insurance benefits to be paid directly to the physician.
  • I understand that I am financially responsible for any balances that are not reimbursed by my insurance company.
  • I agree to inform the staff of St Pete Urology of any changes in my insurance coverage.
  • I agree to pay any deductibles and/or copayments at the time service is provided.
  • If I cancel an appointment within 48 hours of my scheduled appointment or do not show up for a scheduled appointment without any notification, a $25.00 fee will be billed to my account.