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BALBOA NEPHROLOGY MEDICAL GROUP, INC

BALBOA NEPHROLOGY MEDICAL GROUP, INC 2026

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The document is a receipt acknowledging the patient's receipt of Balboa Nephrology Medical Group's Notice of Privacy Policy and Practices. It outlines the patient's financial responsibilities regarding medical services, including insurance billing, payment obligations for non-covered services, and the importance of understanding their insurance policy. Additionally, it includes consent for reviewing medical records by the California Institute of Renal Research for potential participation in research studies.

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Click ‘Get Form’ to open it in the editor.
Begin by filling in your name and date at the top of the form. Ensure that you provide accurate information as this will be used for your medical records.
In the 'Signature' field, sign your name to acknowledge receipt of the privacy policy. This confirms that you understand your rights regarding your medical information.
Next, complete the 'Financial Policy' section. Here, indicate your understanding of insurance responsibilities and payment obligations by checking relevant boxes.
Fill out the patient information section including details like birth date, address, and relationship to insured if applicable. Make sure all fields are completed accurately.
Review all entered information for accuracy before submitting. Use our platform’s features to save or print a copy for your records.

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2018	4.8 Satisfied (175 Votes)

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