Phone:  (907) 569-1333
Fax:  (907) 569-1433

Patient Portal

Your Right To Privacy

Your Right to Privacy

We respect your right to privacy regarding medical information. May we Share information with your Spouse?

If so, Their Name:
Contact Number:
 

We understand that you may have concerned relatives. Please

I authorize RONALD J. BOISEN, M.D, DARYL M. MCCLENDON, M.D. and/or JEFFREY W.MOLLOY, M.D. to access my electronic prescription records for continued care and further treatment.

I Acknowledge and agree that I have received a copy of RONALD J. BOISEN, M.D, DARYL M. MCCLENDON, M.D. and/or JEFFREY W.MOLLOY, M.D. notice to Privacy Practices. 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.

 

Power of Attorney

Definition: A legal document giving a person the power to make decisions for another person, (e.g. current medical decisions, financial decisions).

Yes No

 

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.

 

Appointment and Procedure Cancellation Policy

I understand that RONALD J. BOISEN, M.D; DARYL M. MCCLENDON, M.D. and JEFFREY W.MOLLOY, M.D. reserve the right to the following in the event that you need to reschedule:

  • $25.00 Charge for cancelled office visit without giving at least one (1) business days’ notice
  • $50.00 Charge for cancelled procedures without giving at least two (2) business days’ notice. This allows other patients to be scheduled into that appointment slot. It also makes it possible to reschedule your appointment more efficiently.

I have read, acknowledged and agree to the terms above.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.