Patient Forms

General Forms

• File

  Florida Advance Directive (PDF)
• File

  Notice Regarding Patient Protections Against Surprise Billing Florida (PDF)
• File

  Patient Rights (PDF)
• File

  Right to Receive a Good Faith Estimate of Expected Charges Notice (PDF)
• File

  Language Assistance (PDF)
• File

  Non-Discrimination Notice (PDF)
• File

  Privacy Notice (PDF)

Florida Transparency Bill

• File

  Financial Policy (PDF)
• File

  Financial Verification Form (PDF)
• File

  Patient Financial Responsibility Acknowledgement_SEFL (PDF)

Services may be provided by other healthcare providers who may bill separately.

Charles Aiesi Consulting, Inc. d/b/a Broward Medical Lab
181 W Prospect Rd
Oakland Park, Florida 33309

(954) 739-7764