Treatment consent for a minor:
I (parents/guardians) authorizes Gilbert respiratory associate to examine andtreat 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.