PERSONAL DATA AND APPOINTMENT REQUEST FORM


 


 



I have downloaded and read the Office Policies and Informed Consent, the Financial Agreement, and the HIPAA Notice documents available on https://www.drmayaklein.com and I agree and consent to all policies. I have had the opportunity to ask questions about all policies. Dr. Maya Klein may use any insurance billing company to submit my information if I am using insurance and that I will receive either post or email billing at the addresses provided above containing my statements.