Patient Center

Patient Forms

Please print and complete the forms packet below before your appointment and bring them with you to your appointment.

Forms Packet

  • Patient Forms Packet- 11 pages
  • HIPAA Privacy Notice- For Your Records
  • HIPAA Privacy Notice - Español- Para su registro

Individual Forms

If you need an individual form, please choose from the list below.

  • Patient Information
  • Medical History
  • Medical Records Release
  • Patient Consent
  • Authorization to Treat Minor
  • Policy on Insurance
  • Financial Policy
  • HIPAA Privacy Notice
  • HIPAA Privacy Notice - Español- Para su registro
  • HIPAA Privacy Acknowledgement

Consent Forms

Please choose the appropriate consent form below, print it, and bring the completed form with you to your appointment.

  • Gastroenterological Procedure & Sedation Administration
  • Colonoscopy
  • Capsule Endoscopy
  • Flexible Sigmoidoscopy
  • Endoscopic Ultrasound
  • Esophagogastroduodenoscopy
  • Endoscopic Retrograde Cholangiopancreatography
  • EGD & PEG Tube Placement

Insurance Accepted

This is only a small list of the insurance companies we participate with.  Please contact our office to verify that our practice participates with your plan.

  • America's Choice Provider Network
  • BCBS Florida
  • Cigna Healthcare
  • Florida Medicaid
  • Wellcare/Staywell
  • Humana Medicare/Humana Medicaid
  • Medicare
  • Preferred Care Partners
  • Medica
  • United Healthcare
  • United Healthcare Neighborhood
  • Healthsun
  • Molina Healthcare

Appointment Policy

All visits are by appointment only. Walk-in appointments are not available. Please contact our office to schedule an appointment. If you are not able to keep your appointment or need to reschedule, kindly notify our office at least 24 hours in advance. If you do not come to your appointment, a fee of $35 will be charged.

Billing/Financial Policy

We are committed to providing you with the best possible care. In order to achieve this goal, we need to ensure your understanding of our payment policy.

Payment for services is due at the time services are rendered. We accept cash, MasterCard, Visa and American Express. To ensure a stress-free visit, please verify that Dr. Bruce Le participates with your insurance plan. It is not possible to keep up with all plans available today.

Claims for insurance companies with which Dr. Le participates, are submitted electronically. For those insurance companies with whom we do not participate, we are pleased to provide you with an itemized bill that you can submit for reimbursement.

All co-pays and coinsurance amounts are due at the time of service and, cannot be waived. All patient balances, as determined by your insurance company, are due and payable within 30 days of our invoice. All balances over 30 days are automatically forwarded to our billing company. All balances over 60 days are automatically referred to a collections agency and assessed a $100.00 collection fee. Please pay your balance promptly. If you have financial difficulties, please notify us as soon as possible to avoid this eventuality.