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Patient Portal

Patient Information Form

Patient Information

 
 
 
 

Primary Insurance

 

Secondary Insurance

 

Patient is responsible for all fees regardless of medical coverage. It is customary to pay at the time of service unless other arrangements have been made in advance.

I authorize Ronald J. Boisen, M.D., Daryl M. McClendon, M.D. and/or Jeffrey W. Molloy, M.D. to administer medical treatment.

 

I authorize Ronald J. Boisen, M.D., Daryl M. McClendon, M.D. and/or Jeffrey W. Molloy, M.D., 3851 Piper Street, Suite U466, Anchorage, AK 99508 to release any medical information required by my insurance company or Worker’s Compensation carrier for the processing of all medical claims on my behalf. and to pay benefits directly to Ronald J. Boisen, M.D., Daryl M. McClendon, M.D. and/or Jeffrey W. Molloy, M.D., 3851 Piper Street, Suite U466, Anchorage, AK 99508 for claims on my behalf. I agree to promptly sign over any checks that I receive within 7 days of receipt. I understand that those charges not covered by my insurance company are my own responsibility, and there is a monthly charge of 1% on the account over 90 days. In the event that my insurance company pays Ronald J. Boisen, M.D., Daryl M. McClendon, M.D. and/or Jeffrey W. Molloy, M.D., a fee which I have already paid, I understand that I will be promptly reimbursed.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.