Forms | Insurance | Billing

Patient Forms

Save time by downloading and filling out the necessary forms prior to your appointment. Click below to download a form or additional information.

•    Patient Rights and Responsibilities
•    Consent to Resuscitative Measures
•   Physician Financial Interest or Ownership Relationship in the Facility

Note: To view or print these forms, you will need Adobe Acrobat Reader. Click here to download it.

Participating Insurance Providers

• Aetna – Indemnity, PPO, POS, HMO & Medicare Replacement Policies
• BCBS – All commercial (PPO, Traditional PHS, Network Blue) and Medicare Advantage/HMO plans
• Care Plus – Medicare Advantage Plan
• Coventry – All commercial and Medicare Plans
• Medicare
• Medicaid (State of Florida) – No primary HMO’s at this time.
• Self-Pay
• Tricare – Standard
• Tricare – Prime
• UHC – All Commercial, Medicare Replacement and Advantage Plans
• Workers Compensation

We also accept the following insurances:

• CIGNA – All Commercial and Medicare Replacement Plans
• Humana – All Commercial and Medicare Replacement Plans
• Any other plans with Out of Network Benefits

Billing & Payment

The center requires payment of your deductible, copays and coinsurance before or on the day of your surgery. Please call our office prior to your surgery date if payment arrangements are necessary.

To make a payment on your account, please click here: www.patientnotebook.com/spsctampa

Prior to your surgery, you may request to receive a reasonable estimate of charges. The estimate is based upon your current insurance benefits. Post-surgery, upon request, you may request an itemized bill of charges.

Service bundle information is a non-personalized estimate of cost that may be incurred by the patient for anticipated services. Actual costs will be based on services actually provided to the patient. It is your right to request a personalized estimate from the center. Please reach out directly to the center on our policies on financial assistance, charity care, and collections procedures.

For more information: pricing.floridahealthfinder.gov

Transparency in Health Care

While your medical procedure may be provided in the ASC by the facility, as well as other health care providers who may separately bill you for their services, they may or may not participate with the same health insurers or health maintenance organizations as the ASC.

Prior to your surgery, you may request from the ASC, and other health care providers, a more personalized estimate of charges and other information. You may also contact each health care practitioner who will provide services in the facility to determine the health insurers and health maintenance organizations that the health care practitioner participates as a network provider or preferred provider.

Here is a list of the health care practitioners and medical practice groups with which we’ve contracted with to provide services in our facility.

• Team Health, Gulf-to-Bay Anesthesia Group 
  400 N. Ashley Drive, Suite 1625
  Tampa, FL 33602
  (813) 868-7499
• AccuPath Laboratories 
  5938 Frond Way
  Apollo Beach, FL 33572
  (813) 641-0466
• BayCare Laboratories
  8020 Woodland Center Blvd
  Tampa, FL 33614
  (800) 324-7853
• Implantable Provider Group (IPG)
  11605 Haynes Bridge Road, Suite 200
  Alpharetta, GA 30009
  (770) 753-0046
• Reliance Pathology
  5755 Hoover Blvd
  Tampa, FL 33634
  813-490-7206

   Download Full List of Contracted Health Care Practitioners and Medical Practice Groups.

Charity Care and Financial Hardship

The center maintains a charity care and financial hardship discount policy to provide financial assistance to patients who receive care but do not qualify for state or federal assistance and who are unable to pay the estimated financial responsibility in full. The patient must complete an application and meet the household income qualification based on Federal Poverty Level Guidelines, which are revised annually. Patients will also need to submit supporting documentation as outlined in the application.

The center also provides several payment options for patients who are unable to pay the estimated financial responsibility in full. We accept CareCredit for medical procedures as well as payment plan options that are set up for automatic electronic deductions.

Patients may access the State of Florida’s Agency for Healthcare Administration website for more information about the center. www.floridahealthfinder.gov