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*Patient Name

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Emergency Contact Name

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I give the medical office staff permission to leave messages regarding my medical care and/or appointment confirmation through

Referring Physician Name

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Primary Care Physician Name

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Pharmacy Name

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I hereby authorize release of any medical information necessary to process this claim. I certify that the information given by me in applying for payment under the Title XVIII of the Social Security Act is correct. I request payment authorized by Medicare or other insurances be made either to me or on my behalf to (Provider) for any services delivered by that provider. Authorize any holder of medical information about me to release to the HCFA/ Health Insurance Carrier and its agents for any information needed to determine these benefits or the benefits payable for related services. Further I agree that I am financially responsible for charges incurred that are not covered by my insurance.

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Get started on your wellness journey now by booking an appointment with us. Our pulmonologist believes in providing focused consultation and treatment to his patients making sure all their ailments are being addressed. Give us a quick call, or click on “book an appointment” on our homepage

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Lung and Sleep Disorder Center

(734) 283-5555

734-283-1600

18025 Fort St, Riverview, MI 48193

Lung N Sleep Disorder Center

(248) 327- 7634

(248) 327-7641

(248) 781-6610

26245 Southfield Rd, Lathrup Village, MI 48076

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The content provided on this page is solely intended as general information. It should not be, in any circumstances be used to diagnose, treat, or prevent any ailment. We strongly advise our audience to visit a licensed healthcare practitioner for timely management of any disease.

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Lung and Sleep Disorder Center

Lung N Sleep Disorder Center