Forms for our patients to fill out.

If you are a new patient to our office you can download these forms to fill out.

If you have insurance you will need to fill out:

• Confidential Patient form page 1 & 2
• Patient consent form
• Insurance Policy
• Read the HIPAA privacy policy page 1 & 2

If your insurance is covered through American Specialty Health
you will also need to fill out:

• ASHP Initial authorization form

If you are a Medicare patient:

• Confidential Patient form page 1 & 2
• Patient consent form
• Insurance Policy
• Read the HIPAA privacy policy page 1 & 2
• Please read the Medicare coverage form

If you are a cash patient you will need to fill out:

• Confidential Patient form page 1 & 2
• Patient consent form
• Financial Policy
• Read the HIPAA privacy policy page 1 & 2

If you are a returning patient
insured by American Specialty Health
and need additional visits authorized:

• Followup authorization form

Financial Policy

Insurance Policy

HIPAA Privacy Policy page 1

HIPAA Privacy Policy page 2

Confidential Patient form page 1

Confidential Patient form page 2

ASHP Initial authorization form

ASHP Followup authorization form

Patient consent form

Medicare coverage informational form

4769 Soquel Dr., Soquel Ca. 95073 (831)462-3350