Forms
To save time:
- Please download the appropriate forms
- Bring completed copies of the respective Forms to your appointment.
Note: You will need Adobe ® Acrobat reader to view and print out the forms which have been saved as .pdf files. If you do not have Adobe Acrobat reader, you can obtain a free copy through this link.
If you are a new patient:
- Form: New Patient Registration – English
- Form: Initial History Questionnaire
- Form: New Patient Registration – Spanish
If you want your medical records to be transferred:
For other specialized services:
Circumcision:
- Form: Permit for Circumcision
- Form: Home care after Circumcision
Ear Piercing:
- Form: Consent for Ear Piercing
- Form: Home care after Ear Piercing
Payments
We accept payment in the form of Cash, Check, Visa or Master Card.
As a courtesy to our patients, we bill most insurance companies. However, in the event of copayment, non-covered services, previous unpaid balances, etc., we require payment at the time of visit.
Please review below documents:
Billing
If you have questions with regards to billing, please contact our billing service at:
NextGen Office RCM
Phone: (855) 807-9434
Fax: (469) 519-1448
Insurance
Because we work with many insurance plans, we are unable to know the specifics of your particular plan. Please become familiar with the details of your insurance plan: structure (e.g. HMO, PPO, EPO, POS, etc.), type of coverage, and out-of-pocket costs (i.e. copayments, deductibles, non-covered services, etc.).
We also request that you bring your insurance card to every visit for verification. If you do not have the appropriate insurance information, you may be charged for the visit.
The list of insurance plans below are examples of accepted plans and subject to change without notice. Please check with your insurance company for the most up-to-date information.
PPO Plans
| Aetna | 1-800-756-7039 | ||
| Amer-Net | |||
| BCE Emergis (BPS) | 1-800-247-3315 | ||
| Beach Street | 1-949-672-1398 | ||
| Blue Cross of California | 1-800-765-4446 | ||
| Blue Shield of California | 1-800-424-6521 | ||
| CCN (First Health) | |||
| Choice Care (Humana) | 1-800-626-2741 | ||
| Cigna | 1-800-722-6059 | ||
| Cigna AIM | |||
| Cigna (Open Access) | |||
| Community Care Network | 1-858-547-2502 | ||
| Corvel | |||
| Galaxy Health Network | |||
| Great-West (One Health) | 1-800-663-8081 | ||
| Health Net | 1-800-638-3889 | ||
| Interplan | 1-209-473-0811 | ||
| Multi Plan – Admar – Health EOS – Med Network – AHC – ForMost – Health Network – Preffered Plan – ProAmerica – BCE Emergis |
1-562-598-2266 | ||
| Nation Wide Health | 1-800-226-5116 | ||
| Pacific Care | 1-800-624-8822 | ||
| PacifiCare Health Alliance | 1-916-366-5763 | ||
| PPO Net | 1-805-582-9309 | ||
| Preferred Health Network | 1-720-529-4400 | ||
| Private Health Care Systems (PHCS) | |||
| SaaGii | |||
| Tri-Care | |||
| United Health Care | |||
| USA Managed Care | |||
| USA Health Network | 1-800-872-0820 |
POS Plans
| Aetna | (PMG/ SCCIPA) | 1-800-756-7039 | |
| Aetna (USAccess) | |||
| Blue Cross of California | (PMG) | 1-800-765-4446 | |
| Blue Shield (Access Plus) | (PMG/ SCCIPA) | 1-800-424-6521 | |
| California Care | (PMG) | ||
| California Care (Direct Access) | (PMG) | ||
| Cigna | (PMG/ SCCIPA) | 1-800-722-6059 | |
| Great-West (One Health) | (PMG/ SCCIPA) | 1-800-663-8081 | |
| Health Net | (PMG/ SCCIPA) | 1-800-638-3889 | |
| Pacific Care | (PMG/ SCCIPA) | 1-800-624-8822 | |
| PHN Health Net Select | (SCCIPA) | 1-800-756-7039 | |
EPO Plans
| Aetna | (SCCIPA) | 1-800-756-7039 | |
| BCE Emergis (BPS) | (PMG) | 1-800-247-3315 | |
| Blue Cross of California | 1-800-765-4446 | ||
| Blue Shield of California | 1-800-424-6521 | ||
| Health Net | (PMG) | 1-800-638-3889 | |
| Nation Wide Health | 1-800-226-5116 | ||
| PPO Net | (SCCIPA) | 1-805-582-9309 | |
| United Health Care | |||
HMO Plans
| Santa Clara IPA | (SCCIPA) | ||
| Physicians Medical Group | (PMG) | ||