FORMS
Here you will find links to forms and other documents that you will need prior to your initial office visit. You will also find resources that can help you in your journey to becoming a healthier and better you.
As a new patient you will be required to fill out a rather extensive Medical History Questionnaire as well as other forms pertaining to privacy and financial responsibility. These can be downloaded from here and can be filled out by you or your designee in the comfort of your own home. The new patient packet contains all the forms you will need or you can download them individually. We believe this will expedite your check-in process. Please bring them with you along with your insurance card, driver's license and your co-payment.
Remember, without your cards we will be unable to see you.
If you have any questions or problems filling out these forms, or have questions regarding co-payments or financial issues, please call the office at (239) 263-4470 for clarification. These forms are also available at the office should you wish to fill them out here. In that event please arrive at the office 30 minutes early to fill out your information.
Thank you,
Dr. Joseph G. Spano, M.D.P.A.
DOWNLOAD FORMS:
PATIENT INTAKE FORM
MEDICAL HISTORY QUESTIONNAIRE
INSURANCE, RESPONSIBLE PARTY, HIPPA NOTICE, MEDICAL INFORMATION RELEASE FORMS
DR. SPANO'S ACCEPTED INSURANCE (Medicaid & HMO's not accepted)
Please verify insurance information directly with your doctor's office as it may change frequently.
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Aetna Choice POS II
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Aetna Managed Choice POS
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Aetna Managed Choice POS Open Access
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Aetna Signature Administrators PPO
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BCBS Blue Card PPO
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CIGNA Open Access Plus
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CIGNA PPO
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Coventry FL Employer Group PPO
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First Health PPO
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Florida Blue BlueOptions
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Humana ChoiceCare Network PPO
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Humana National POS
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Medicare
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Multiplan PPO
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PHCS PPO
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UHC Choice Plus POS
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UHC Navigate POS
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UHC Options PPO