PHYSICIAN OWNERSHIP DISCLOSURE FORM

During the course of your physician / patient relationship with Dr. Rizwan H. Bukhari, Dr. Bukhari may refer you to Baylor Scott & White Medical Center – Sunnyvale (“Hospital”).
The address of the Hospital is 231 South Collins Road, Sunnyvale, TX 75182.
This notice is being provided to advise you that Dr. Bukhari has an investment interest in the Hospital.
This information is being provided to help you make an informed decision about your health care. You have the right to choose your health care provider(s). You have the option of obtaining health care ordered by your physician at a different facility other than Baylor Scott & White Medical Center – Sunnyvale. You will not be treated differently by your physicians or Baylor Scott & White Medical Center – Sunnyvale if you choose to use a different facility. If desired, your physician can provide information about alternative hospital providers.

 

If you have any questions concerning this notice, please feel free to contact:

Jodi Bullard – Office / Clinical Manager
(972) 855-8346

Your signature below acknowledges your understanding of the above mentioned information and of your right to seek health care by providers of your choosing.

 

Date: ____________________, 20_____

 

Signature of Patient: _________________________________________________

Printed Name of Patient: _____________________________________________

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