Concerns or Complaints
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Records Request (records to us)
This form can be filled out and sent to any physician or hospital that has records that you would like copied and sent to us. Use this for any medical care you might have obtained prior to seeing us that you think we should review.
Patient Information Form - NEW PT
All new patients must fill out this form. Thank you for your understanding.
Patient Information Form - Return WW
This is a shorter version of our usual form, for returning annual exam patients.
Insurance Information Form
Your insurance information - we need this to be able to bill your Insurance.
Records Copy Form (records from us)
You can have a copy of your medical records sent either to yourself or to a designated provider. Records can be sent by paper or electronically or on a thumb drive (extra fee for this).
Fill out this form, sign and date it, and then mail (or e-mail) it to us. There is a $30 one-time fee to cover staff time and materials used.
Being Referred Handout
If you are being referred to a specialist, here is some useful advice.
Financial Policies Handout
This form outlines our office's financial policies.
HIPAA Privacy Notice
A copy of this is given to all new patients at their initial visit. In compliance with the federal law known as HIPAA, it describes in detail what we may or may not do with your private health information (PHI).
Patient Bill of Rights
Our statement of your rights and responsibilities as our patient.
California State Disability (SDI)
This form is used to apply for California State Disability (SDI) benefits. DO NOT submit this form until you have STOPPED working. Then fill out your portion including the last day that you worked. After that, give us the form (or send it) and we will complete it and file it for you.
Your SDI disability claim can also be done online.
Tutorial for online EDD claims