Dr. Eduardo Tanner

  
 DocuSign Envelope ID: B12637F7-7012-4F35-BE12-EA9EC5ACCE12 
 TBOSG 
 TAMPA BAY ORTHOPEDIC 
 SURCERY GROUP 
 PATIENT FINANCIAL AGREEMENT (PFA): 
 AUTHORITY TO TREAT AND GUARANTEE OF PAYMENT FOR MEDICAL SERVICES 
 Betty James
 Re: 
 Patient Printed Name: 
 (hereinafter "Patient") 
 Date of Birth: 97/12/24
 Date of Incident: 23/01/28
 Initial: 
 os 
 ww 
 1. 
 Tampa Bay Orthopedic Surgery Group (hereinafter "the Practice") has agreed to provide 
 medical care to the Patient. 
 aw 
 2. 
 Because the Patient is being seen at this medical practice due to injuries received as a 
 result of a traumatic event, this document becomes reasonable and necessary.  
 3. 
 Presently, the Patient is not a subscribing member of any group or individual commercial 
 health insurance policy and/or does not participate in any government sponsored health insurance 
 plans (Medicare, Medicaid, Tricare, etc.) OR the Patient does possess valid health insurance or a 
 sponsored health plan but requires medical care which may not be fully reimbursable under said 
 policy or program. 
 4. 
 The Patient understands that this type of Patient Financial Agreement/Authority to Treat 
 and Guarantee of Payment is vastly different from the traditional contractual relationship 
 
 3812 Tampa Rd. Suite 300 Palm Harbor FL 34684 P: 727xxxxxxx F: 727xxxxxxx
 7812 66th St. N. Suite 204 Pinellas Park FL P: 127.712.7112 F: 123.412.2812
