Dr. James A Sotrop
19021 N. Dale Mabry Hwy.
Lutz, Fl. 33548
Permission for Treatment
I the undersigned, herby voluntarily consent to medical / diagnostic treatment and or minor surgical
treatment and by James A. Sotrop, M.D. deemed advisable and necessary in the diagnosis and
treatment of my condition. I am aware that the practice of medicine is not an exact science and I
acknowledge that no guarantees have been made to me as a result of treatment or examination in the
office. I authorize the release of any of my past/ current medical records that are needed for my
treatment from any prior healthcare providers.
Initial Here: __________
Authorization and Assignment
I herby authorize payment directly to James A. Sotrop, M.D. for all insurance benefits otherwise payable to me for
services rendered. I understand I am financially responsible for all charges, whether or not paid by insurance, and
for all services rendered on my behalf or my dependents. Fees incurred in Collection Litigation of any unpaid
balances will become the responsibility of the patient guarantor. An interest rate of 1.5% per month will apply to
balance past 90 days in delinquency. I authorize the above medical provider to release the information required to
secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
I request that the payment of Authorized Medicare/ Insurance Benefits be made either to me or on my behalf for
any services furnished by James A. Sotrop, M.D. I authorize any holder of medical information about me to release
to CMS/ Insurance Carriers and its agents any information needed to determine these benefits or benefits related
to service. I hereby authorize (assign) my Insurance Carrier(s)/ CMS to make payment directly to James A. Sotrop,
M.D. for medical, diagnostic and surgical benefits payable for the services rendered. I understand that any unpaid
balance not covered by this policy will be payable by me. I understand that CMS and/or other insurance carriers
do not cover all office services/ procedures. I agree to take full responsibility for any unpaid balances and that
such payment will be made to James A. Sotrop, M.D. for services rendered. I certify that the information I have
given here is true and correct to the best of my knowledge. I will also notify you of any changes in my status or
changes in the above information.
Initial Here: __________
Designated Relative(s)
I authorize Discussion and release of My General Medical Condition and Diagnosis (including treatment, payment
and healthcare operations.) Please List the family members or significant others, if any, whom we may inform
about your medical condition, and/or in case of an emergency:
Name: _____________________________ Relationship________________ Phone Number_________________
Name: _____________________________ Relationship________________ Phone Number_________________
Hipaa Privacy Notice
I have reviewed and/ or been given a copy of James A. Sotrop, M.D.’s Privacy Notice. I have read and
understand the above information and I consent to all of the above.
Patient Signature: ____________________________________________ Date: ___________________________