To accurately expedite the flow of information from you to our office, and to help us prepare your chart in advance of your visit, there are 3 forms requiring your attention.
The first form is a demographic form. The second form is a health history questionnaire. The third form is a patient privacy form known as a HIPAA form (Health Insurance And Portability Accounting Act.). It explains how your health information is protected and allows you to designate who, if anyone may receive information about you from us.
You may submit these forms directly to us online. This is our preferred method of submission. It is secure and is transmitted using SSL technology. The second method is performed by typing your information on your screen, downloading it, printing it on your printer and faxing it to us at (310)273-0314. The third method of communication allows you to print out the forms, fill them in by hand and either fax them to us or bring them to our office. We would ask that if you use this method of transmission, you arrive at our office 30 minutes in advance of your appointment to allow us to assemble your chart.
If you are a patient requesting a release of your medical records, please complete and download the following form. THE FORM MUST BE ACCOMPANIED BY A SIGNED AND DATED PHOTO IDENTIFICATION SUCH AS A DRIVER’S LICENSE OR PASSPORT. You may then fax the form and the signed and dated photo identification to us at (310) 273-0314.
- Request for release of medical records (Click on the hyperlink to open, fill in the form, download, print and fax to us. THE FORM MUST BE ACCOMPANIED BY A SIGNED AND DATED PHOTO IDENTIFICATION SUCH AS A DRIVER’S LICENSE OR PASSPORT. )
Once you have submitted the forms online or by fax, please call our office at (310) 273-2310 to confirm receipt of your information.