Office Policies and Forms

Patient Forms

Adults

Patient Letter
Patient Registration Form Updated
Registro del Paciente Updated
Patient Consent
Confidential Health History
Notice of Privacy Practices

Children

Pediatric Initial History, Birth to 5 Years
Pediatric Initial History, 6 to 20 Years
Consent To and Direction for Treatment of Minor
Permiso e instrucciones para el tratamiento de un menor de edad
Historia Pediátrica Inicial, Desde el nacimiento hasta los 5 años
Historia Pediátrica Inicial, De 6 a 20 años

Accessibility

IIt is our intention to provide needed services to women and children of all races, classes, religions, physical abilities, cultures, ages and sexual orientations. The building is wheelchair accessible. We have bilingual staff on hand to serve our Spanish-speaking clients. Please let us know if you have special accessibility needs and we will try to meet them.

Sliding Scale Rates and Types of Insurance

We charge fees on a sliding scale according to income. CCAH, Medi-Cal, MediCare and major credit cards are welcome. We are able to accept some insurance plans for direct billing. Call our office at (831) 427-3500 for information about fees or billing.

Governmental Programs

We provide low or no-cost services through state funded programs for low-income, uninsured and underinsured residents through the following programs:
Family PACT: birth control, sexually transmitted infection testing and treatment, pregnancy testing, annual exams, etc.
BCEDP: Breast Cancer Early Detection Program for breast exams and mammograms
CHDP: Child Health and Disability Program for well child exams and immunizations
EAPC: Expanded Access to Primary Care for sick visits and preventative health care
Healthy Families: sick visits and preventive health care for children

Eligibility for these programs is based on income level and insurance coverage. Call (831) 427-3500 to learn more about whether you are eligible.

Updated March 23, 2010