New Member Form
To enroll in Dr. Chan’s personalized care practice, download and print the New Member Form by clicking on the link below. For your convenience, please fill out the New Member Form prior to your scheduled visit to Dr. Chan’s office. Should you have any questions about the contents of the New Member Form, please do not hesitate to call the office during normal business hours.
The complete list of insurance providers that Dr. Chan is currently contracted with as an in-network participant, include:
• Blue Cross Blue Shield of Arizona
• United Health Group, Inc. – Americhoice
Patients should call their representative insurance member services to verify in-network participation. For Rejenesis billing questions, contact our office at (480) 961-2366.
Terms and Conditions
To view the complete Terms and Conditions for Dr. Chan’s concierge care members, click the link below.
New Patient Registration >
Health History Questionnaire >
Authorization to Release Health Information >
Acknowledgment of Receipt of Privacy Policies >
Physician - Patient Arbitration Agreement >
Financial Policies >
Narcotic Agreement >
Notice of Privacy Practices>
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