If you are coming in for your first visit you can find our new patient paperwork below. Download the form by clicking on the name. If you are having difficulty opening the file please download Adobe Reader by clicking the icon below.
New Patient Form
- Please bring a photo ID, insurance cards, and a list of any medications you take.
Effective Date: 01/01/2018
Failure to keep your scheduled appointments hinders our ability to provide the best care to you. In order to restrict missed appointments, we have implemented an Appointment Cancellation / No Show Policy. We ask that in the event you need to cancel your appointment, you call at least 24 hours prior to an office visit, and 72 hours prior to surgery. This will allow us the opportunity to offer that appointment to another patient. Late cancellations / missed appointments due to illness or family emergency are excluded from this policy.
Repeated late cancellation and missed appointments are disruptive to the optimal delivery of care to you and other patients. As a results, three (3) late cancellations or missed appointments may result in the discontinuation of your care with Dr. Roberts. In the event that you are dischared from care, your referring provider will be notified of the reason for discharge from our practice.
Failure to give notice prior to cancellation will result in an "Appointment Cancellation Fee" of twenty-five (25) dollars. Missed appointments will be assed the same fee. This fee cannot be billed to your insurance company and will be your direct responsibility.
Our practice firmly believes that a good physician/patient relationship is based upon understanding and communication. Questions about cancellation and no show fees should be directed to the Billing Department (850-650-9462).
We are in network with Blue Cross Blue Shield, Cigna (including Healthspring), Humana, Medicare, Tricare, United Healthcare, and several other major PPO plans. Please check with your insurance carrier to ensure specific benefits, such as routine footcare.
You may have a co-pay that is due at the time of service. Our staff strives to be as accurate as possible when calculating your resposibility. However, with so many variations in plan requirements, additional may be due after insurance has proccessed the claim. If there is still a deductable to be met on your plan we will first file to the insurance to ensure we collect an accurate payment. Please be aware that most insurance claims take two to three weeks to fully process.
Statements are sent out at the beginning of each month with any balance due. We accept American Express, Discover, Mastercard, Visa, personal check, and cash for your convenice.
Although co-pays are due at the time of service and account balances are due upon receipt of first statement, payment plans can be arranged in unusual circumstances on a case by case basis.
If you have any questions reguarding your account please contact our billing department at 850-650-6492.
Updated Notice of Privacy Practices: 12/27/17
Original Effective Date: 4/14/2003
This notice describes how your medical information may be used and disclosed and how you can gain access to it.
Please review it carefully.
Each time you visit a physician, hospital, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination, test results, diagnoses, treatment, plan for future care or treatment, and billing-related information. Your record represents Protected Health Information. We are committed to treating and using Protected Health Information about you responsibly. This Notice describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your Protected Health Information. This Notice applies to all protected Health Information, as defined by federal regulations, which are generated by our office.
For Treatment: We may use your health information to provide you with medical treatment or services. We may disclose medical information about you to other health professionals who contribute to your care (such as doctors, nurses, technicians, or other personnel who are involved in taking care of you).
For Payment: We may use and disclose medical information about your treatment and services to bill and collect payment from you, your insurance company, or a third party payer. For example, we may need to give your insurance company information about your treatment so they will pay us for the treatment. We may also tell your health plan about treatment you are going to receive to determine whether your plan will cover it, unless you exercise your right to restrict.**
For Healthcare Operations (Business Associates): There are some services provided in our office through contracts with business associates. Examples included transcription of your dictated health information, a copy service making copies of your health records, e-Prescribing service, a person who provides data transmission services, computer software vendor, and subcontractors that create, receive, maintain, or transmit your medical information on behalf of the contracted Business Associate as required for Omnibus HIPPA Rule compliance. When services such as these are contracted, we may disclose your health information to our business associates so that they can perform the job we’ve asked them to do. To protect your health information, however, we require the business associates to appropriately safeguard your information as required by HIPPA regulations.
Communication with Family or Friend: We may release medical information about you to a friend or family member who is involved in your medical care of who helps pay for your care.
For Research, Marketing, or Fundraising: We may disclose information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved their research. Our office does not sell your protected health information. Any activity for research, marketing, and fundraising requires your written authorization.
We may also use and disclose medical information to/for the following:
- to remind you of your appointment
- to assess your satisfaction with our services
- for law enforcement purposes or in response to subpoena
- to notify or assist in notifying a disaster relief entity
- Food and Drug Administration
- Funeral Directors, Coroners, Medical Directors
- Health Oversight Agencies
- Legal Authorities
- Military Command Authorities
- National Security & Intelligence Agencies
- Organ and Tissue Donation Organizations
- Protective Services for the President of the United States
- Public Health Authorities
- Workers Compensation Agents
Although your health record is the physical property of this office, you have the right to:
Inspect and copy: You have the right to view your Protected Health Information, obtain a copy of the information, or both. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. We are allowed to charge you for these copies. If capabilities exist, you may request access to your medical records in electronic format.
Amend: If you feel that medical information is incorrect or incomplete, you may ask us to amend (not change) the information. We may deny your request for amendment; and if this occurs, you will be notified of the reason for the denial.
Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you. We are not required to agree to your request. If we do agree to the requested restriction, it will be honored with the exception of permitted disclosures, including emergency treatment, public health authority, Food and Drug Administration, work-related injury, and OSHA compliance.
**Restricted Disclosure: You have the right to restrict disclosure of your personal protected health information to your health plan/insurance company if that information pertains solely to healthcare for which you (or a person on your behalf) paid for the testing or treatment in full, out of pocket. You must continue to pay out of pocket for subsequent care related to restricted disclosure.
Genetic Information: Your genetic information is treated as Protected Health Information. It cannot be used to discriminate again you for the provision of health insurance or for the underwriting process.
Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location (for example, at work, or by U.S. Mail). We will grant this request only if it is submitted in writing. We reserve the right to contact you by other means and or other locations if you fail to respond to any communication from us that requires a response.
Breach: You will be notified within sixty days if a reportable breach of your protected health information occurs.
We reserve the right to change this notice and to make the new provisions effective for all Protected Health Information we maintain from the first date of your health record. The current notice will be posted and include this effective date.
If you believe your privacy rights have been violated, you may file a complaint by contacting the Privacy Officer in our office. All complaints must be submitted in writing. You will not be penalized for filing a complaint. You may revoke your permission to use or disclose medical information about you, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.