Pre-Procedure Information

Financing Available Through Care Credit

To our Patients:

Gulf Coast Endoscopy Center’s management and staff care about the treatment their patients receive. If at any time we fail to meet your expectations, please feel free to ask for the administrator or supervisor on duty.

Administrator:
Terri Lopez, CASC, CMM
941.484.5000, ext 124
tlopez@gulfcoastendocenter.com

We are required under the provisions of Florida Patient’s Bill of Rights and Responsibilities to inform those patients who inquire regarding filing of complaints with the State of Florida the following information:

Complaint Against Health Care Professional or Facility

Florida Department of Health
Consumer Services Unit
4052 Bald Cypress Way, Bin C-75
Tallahassee, FL 32399-3275
1-850-245-4339
http://www.doh.state.fl.us/mqa/enforcement/enforce_csu.html

Consumer Assistance Notice

Agency for Health Care Administration
2727 Mahan Dr
Tallahassee, FL 32308
1-888-419-3456

The Department of Insurance State of Florida Abuse Registry
200 East Gaines St. 1-800-96-ABUSE
Tallahassee, FL 32399
1-877-693-5236

Office of the Medicare Beneficiary Ombudsman:
http://www.medicare.gov/Ombudsman/resources.asp

If you need the address and toll-free telephone number of the grievance department of any of our contracted HMOs, please ask one of our business office employees.

Please feel free to ask for a copy of the Florida Patient’s Bill of Rights and Responsibilities or Gulf Coast Endoscopy Center’s Patient Grievance Policy.

Please click on the form below to complete your questionnaire. Completing and submitting the form will help make your check in process on the day of your procedure a little faster and more comfortable for you. When you click on submit, the form will be transmitted directly and confidentially to the facility to be entered into your medical record. Thank you for your help and allowing Gulf Coast Endoscopy Center of Venice to take care of your health care needs.

OTHER DOCUMENTS FOR YOUR REVIEW

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