Pulmonary, Critical Care, and Sleep Medicine

Virtual Attestation Form

Attestation

  • I acknowledge that I have reviewed my personal demographic information, including my address, phone number, insurance information, and all other personal identification information, and to the best of my knowledge, all information is correct and up to date. I addition, I have reviewed, understand, and agree with the following forms:
    • Patient Information
    • Acknowledgement of Receipt of Notices of Privacy Practices
    • HIPAA Notice of Privacy Practices
  • My electronic signature provides attestation to the accuracy of this information, acknowledgement that "Virtual" office visits and phone call office visits will be billed to my health insurance, and that I will be responsible for any copays, deductibles, and coinsurance that may apply to these visits.