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Physicians
Jed bayasi, MD
Virginia Rowland, MD
Patients Information
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Information Form
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Release Of Records
Hippa
Insurance
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Respiratory
Lung Cancer Screening
Lung Nodule
Sleep Disorder
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Email:Grafax@gmail.com
Phone:480-917-0933
Fax:480-917-8866
Address:3491 S Mercy Rd. Suite 103,Gilbert AZ.85297
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Gilbert Respiratory Associates | Center for Respiratory and Sleep Disorder
Home
Physicians
Jed bayasi, MD
Virginia Rowland, MD
Patients Information
New Patient
Forms
Information Form
Patient Intake
Release Of Records
Hippa
Insurance
Health Education
Health Topics
Patient Health Series
Services
Respiratory
Lung Cancer Screening
Lung Nodule
Sleep Disorder
Appointments
Contact/Map
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Information Form
GILBERT RESPIRATORY ASSOCIATES
PATIENT INFORMATION
Sex
M
F
Marital Status:
S
M
D
W
Treatment consent for a minor:
I
(parents/guardians) authorizes Gilbert respiratory associate to examine and
treat
in the event I cannot accompany him/her to the office appointment.
Responsible Party Information
Insurance Information (MUST BE FILLED OUT)
Financial/Insurance Policy:
I hereby assign all insurance benefits to GRA for services performed as a result of illness or injury. Non-Insured Patients: I agree that I am responsible for payment at the time of service, unless prior arrangements had been made.Collections: Once an account is placed in collection status all future services must be paid in full at the time of service.There will be a $30.00 fee for no-show appointments.
Referral & Insurance Card Patient Responsibility:
I understand that during the check in process, if I do not have my referral and/or insurance card I will be responsible for any payment rendered at the time of service. I also understand that I can avoid this expense by bringing my referral and/or Insurance card to my scheduled check in time or I understand that I can call my referring Doctor's office and have these items faxed to Gilbert Respiratory front office at (480) 917-8866, before the scheduled exam time.
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE FORM
I have had the opportunity to read/review the notice of privacy Practices Form provided to be by Gilbert Respiratory Associates. I understand that a copy would be available upon my request during at the check in/out area.