Common Contracts
1 similar null contracts
Patient Name (last, first, MI): Date of Birth (mm/dd/yyyy): Medical Record #:June 30th, 2016
As either the Patient or the legally authorized representative of the Patient, on behalf of the Patient receiving care in this Physician Group of Arizona, Inc., (PGA) Facility, I make the following consents, understandings, and agreements on my own behalf and on behalf of the Patient in partial consideration of health care services to be provided to the Patient in the PGA Facility, including IASIS Healthcare and its affiliates.
