CONTACT US

12315 Crabapple Road Suite 108 Alpharetta GA 30004 Phone: 678-254-2333 Fax: 678-254-2332

Emails:

Dr. Michael Bianco D.O drmike@biancoprimarycare.com

Dr. Shelley Bianco D.O. drshelley@biancoprimarycare.com

Eileen Smith, Membership/Office Mgmt eileen@biancoprimarycare.com 

Kayla Ray, MA kayla@biancoprimarycare.com

Refills refills@biancoprimarycare.com

PATIENT FORMS PACKAGE

Intake Questionnaires

• New Patient Health Questionnaire
• Patient Demographic Information
• Existing Patient Health Questionnaire

Consent Forms

• New Payment Selection Form
• AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
• ELECTRONIC COMMUNICATIONS AGREEMENT FOR PERSONAL HEALTH INFORMATION
• Notice of Privacy Practices Acknowledgement
• Private Medical Practice Agreement
• New Laboratory Policy and Information