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Chena Obstetrics & Gynecology Intake Form

Chena Obstetrics & Gynecology Intake Form 2025

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4.5 out of 5

63 votes

The document is an intake form and financial policy for Chena Health, a healthcare provider located in Fairbanks, AK. It includes sections for patient information, emergency contacts, insurance details, consent for the release of health information, and acknowledgment of privacy practices under HIPAA. The financial policy outlines payment responsibilities for self-pay and insured patients, including co-pays and deductibles due at the time of service. Additionally, it emphasizes the importance of keeping insurance information updated and provides options for communication regarding health information.

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Versions	Form popularity	Fillable & printable
2022	4.5 Satisfied (63 Votes)
2011	4 Satisfied (54 Votes)

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