Patient Intake Form

I understand and agree that:

Synergy Medical Group may bill my insurance for covered services.

I authorize the release of information necessary to process claims and authorize payment of benefits directly to the practice.

I am financially responsible for all charges not covered by my insurance plan, including copayments, deductibles, coinsurance, non-covered services, and services denied by insurance.

Insurance verification or authorization does not guarantee payment.

I am responsible for providing accurate and up-to-date insurance information.

I agree to pay any outstanding balances in a timely manner.

Unpaid balances may result in late fees, collection efforts, or restrictions on scheduling future appointments.

I understand that Synergy Medical Group charges a $50 fee for any appointment that is not canceled at least 24 hours in advance, and I agree to be responsible for this fee.

I understand that laboratory testing, imaging studies, pathology services, durable medical equipment, prescriptions, and other services performed by third-party facilities are billed independently from Synergy Medical Group.

I am responsible for all charges from outside providers, even if the services were ordered by my Synergy Medical Group provider.

I understand that:

Third-party vendors set their own pricing.

These charges may apply toward my deductible or coinsurance.

Questions regarding these charges must be directed to the vendor or insurance carrier.

I agree to ask Synergy Medical Group if I have concerns about cost or alternative options.

I acknowledge that Synergy Medical Group maintains policies regarding scheduling, cancellations, no-show appointments, and late arrivals. I agree to follow these policies and understand that failure to comply may result in fees or limitations on scheduling future appointments.

I understand that Synergy Medical Group is not an emergency medical service. If I experience a medical emergency, I must call 911 or go to the nearest emergency facility.

I agree to respect the practice’s guidelines for professional behavior, appointment preparation, and timely communication related to my care.

Acknowledgment of Receipt of Joint Notice of Privacy Practices

Florida Rehab Specialists, PLLC d/b/a Synergy Medical Group and Alliance Family Physicians, P.A. share one Joint Notice of Privacy Practices. It explains how your health information may be used and shared, and your rights, including the right to see and get a copy of your records, ask for corrections, ask us to limit how we use or share your information, ask us to contact you in a certain way, and get a list of certain disclosures. You can read it here: https://synergymedicalgrp.com/privacy-practices/. You can ask us for a paper copy at any time.

By signing below, I acknowledge that I have received the Joint Notice of Privacy Practices.