Medical Arts Obstetrics and Gynecology

Registration Form

Please correct the errors described below.


Acknowledgment and Consent

I hereby assign my insurance benefits to be paid directly to the undersigned physician. I am financially responsible for any balance or non-covered service. I authorize the physician to release any information required to process my claim.

I have received the HIPAA Notice of Privacy Practices and have been given a copy if requested.

Disclaimer: 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.

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