• 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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Information Form

GILBERT RESPIRATORY ASSOCIATES

PATIENT INFORMATION

 M F
 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.