Asim Guha Roy, M.D. INC
Asim Guha Roy, M.D. INC

Forms

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New Patient Registration Form
New Patient Registation Form.docx
Microsoft Word document [29.3 KB]
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Patient Medical History Form
Patient Medical History Form.docx
Microsoft Word document [104.5 KB]
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Acknowledgement of Receipt of Notice of Privacy Practices HIPPA
Acknowledgement of Receipt of Notice of [...]
Microsoft Word document [101.8 KB]
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Authorization to Release PHI (from our office)
Authorization to Release PHI (from our o[...]
Microsoft Word document [100.1 KB]
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Authorization to Release PHI (to our office)
Authorization to Release PHI (to our off[...]
Microsoft Word document [101.7 KB]
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E-Prescribing Consent Form
E-Prescribing Consent Form.docx
Microsoft Word document [103.0 KB]
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Out of Network Insurance Reimbursement Request Form
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
Phone: 858-430-6656 858-430-6656
Fax: 858-256-5424
E-mail Address:

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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