Form- Disclosure of Financial Interest

Please see the attached Disclosure of Financial Interest form. It is only to be used by medical providers who own multiple medical corporations and submit bills for a patient under multiple corporations.

Click here to view a nice PDF that you can download for free

For instance, if a Chiropractor is an “investor” in two companies (ie. Chiropractic Inc. and Orthopedic Inc.) and the Chiropractor refers a patient to Orthopedic Inc. for a consultation then this form is absolutely necessary to avoid committing a first degree misdemeanor.

While most chiropractors do not own an interest in Orthopedic offices, many chiropractors choose to bill manipulations under a “Chiropractic Corporation” and therapy under a “Rehab Corporation” for tax and malpractice purposes. Even in those instances, the chiropractor is obligated to provide this form to patients informing them of the financial interest.

Florida law requires the attached disclosure form to include:

  • The name and address of every referring entity which the provider is an “investor”
  • The disclosure of the patient’s right to go to another provider for the referred service
  • The name and address of two alternative offices
  • The posting of this form in a conspicuous place in your office.

Disclosure Of Financial Interest

Pursuant to F.S. §§ 456.052 & 456.053

I, ___________________________, understand that the companies listed below are owned by


the same individual(s).

John Smith, DC PA 123 Main Street, Miramar, FL 12345

John Smith’s Massage Therapy Inc. 123 Main Street, Miramar, FL 12345

John Smith’s MRI Center, Inc. 123 Main Street, Miramar, FL 12345

I understand that this office performs several services in the same office for my convenience so that I don’t have to travel to another office and so that I can receive the same great standard of care I’m used.

I also acknowledge that I have the right to massage therapy, orthopedic treatment, or ____________ treatmentfrom other providers, including but not limited to the two providers listed below:





_____________________ _________________

Patient’s signature Date

456.052 Disclosure of financial interest by production.—

(1) A health care provider shall not refer a patient to an entity in which such provider is an investor unless, prior to the referral, the provider furnishes the patient with a written disclosure form, informing the patient of:

(a) The existence of the investment interest.

(b) The name and address of each applicable entity in which the referring health care provider is an investor.

(c) The patient’s right to obtain the items or services for which the patient has been referred at the location or from the provider or supplier of the patient’s choice, including the entity in which the referring provider is an investor.

(d) The names and addresses of at least two alternative sources of such items or services available to the patient.

(2) The physician or health care provider shall post a copy of the disclosure forms in a conspicuous public place in his or her office.

(3) A violation of this section shall constitute a misdemeanor of the first degree, punishable as provided in s. 775.082 or s. 775.083. In addition to any other penalties or remedies provided, a violation of this section shall be grounds for disciplinary action by the respective board.

History.–s. 1, ch. 86-31; s. 84, ch. 91-224; s. 13, ch. 92-178; s. 92, ch. 97-261; s. 76, ch. 2000-160.

Note.–Former s. 455.25; s. 455.701.


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