Forms
Acknowledgement of Receipt of Notice of Privacy Practices HIPPA
Acknowledgement of Receipt of Notice of [...]
Microsoft Word document [101.8 KB]
Acknowledgement of Receipt of Notice of [...]
Microsoft Word document [101.8 KB]
Authorization to Release Protected Health Information (to our office)
Download this form if you wish for an outside medical facility to release your medical records to our facility.
Authorization to Release PHI (to our off[...]
Microsoft Word document [101.5 KB]
Download this form if you wish for an outside medical facility to release your medical records to our facility.
Authorization to Release PHI (to our off[...]
Microsoft Word document [101.5 KB]
Authorization to Release Protected Health Information (from our office)
Download this form if you wish for our medical office to release your medical records to another medical facility.
Authorization to Release PHI (from our o[...]
Microsoft Word document [99.9 KB]
Download this form if you wish for our medical office to release your medical records to another medical facility.
Authorization to Release PHI (from our o[...]
Microsoft Word document [99.9 KB]
Out of Network Insurance Reimbursement Request Form
Out of Network Insurance Reimbursement R[...]
Adobe Acrobat document [344.4 KB]
Out of Network Insurance Reimbursement R[...]
Adobe Acrobat document [344.4 KB]
Asim Guha Roy, M.D. Inc.
4540 Kearny Villa Rd
#106
San Diego, CA 92123
E-mail Address:
guharoyoffice@gmail.com
Our office is located in the LANDMARK CENTRE, which is conveniently off the CA-163 freeway, Balboa Ave exit. Please refer to the Directions tab for more information.
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