Katherine Acevedo

  
 DocuSign Envelope ID: B6xxxx-70xx-4Fxx-BExx-EA9EC5Axxxxx 
 TBOSG 
 TAMPA BAY ORTHOPEDIC 
 SURCERY GROUP 
 ADVANCED BENEFICIARY NOTICE OF BILLING AND SERVICE OPTIONS (ABN) 
 Shannon Gray 
 By my signature below, I, 
 (print name), hereby 
 acknowledge and understand that Tampa Bay Orthopedic Surgery Group (hereinafter "the Practice"), 
 have offered to provide medical treatment related to my liability incident dated 12/12/2022 
 I 
 have fully read this notice to make an informed decision about the payment for my medical care. I 
 further acknowledge that I have been given the opportunity to ask any questions I may have and to 
 consult with an attorney of my choice to discuss my rights and responsibilities prior to choosing my 
 option and signing this form. 
 (INITIAL ONLY ONE BOX. WE CANNOT CHOOSE A BOX FOR YOU.) 
 DS 
 ww 
 OPTION 1 - Due to the time and nature of treatment to be rendered by the Practice, in 
 addition to the risk in undertaking my medical treatment of either underpayment or nonpayment by my 
 health insurance carrier.
 OPTION 2 - I hereby agree that the Practice will bill my health insurance carrier, Medicare, 
 Medicaid, or other applicable carrier for the medical services by the Practice, but I will be required to 
 pay in full all co-pays, deductibles, co-insurance, or patient responsibility estimated to be payable as a 
 result of the rendering of these medical services prior to receiving any medical treatment. 

 DocuSigned by: 
 (Shannon Gray 
 2022-07-10 
 32E36710500740E 
 Signature of Patient 
 Date 
 Signature of Medical Provider 
 a 
 2022-03-18
 Date 
 1119 W Kennedy Blvd Tampa FL 33606 P: 813.463.2819 F: 813.463.2819 
 3819 Tampa Rd. Suite 300 Palm Harbor FL 34684 P: 727.239.0819 F: 727.239.0619 
 7819 66th St. N. Suite 204 Pinellas Park FL P: 877.703.7119 F: 813.463.2819
