PERSONAL DATA AND APPOINTMENT REQUEST FORM


 


 



I have downloaded and read the Business 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. I understand that Dr. Maya Klein may use an 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.