New Patient Forms

New Patient Packet

Please complete all sections before your first visit. Fields marked * are required. Your information is kept strictly confidential.

Download Records Release (PDF)Download Email Consent (PDF)

Patient Information

First Name *

Last Name *

Date of Birth *

Sex *

Social Security Number (last 4 digits)

Marital Status

Street Address *

City *

State *

ZIP Code *

Primary Phone *

Alternate Phone

Email Address

Employer / Occupation

Occupation

Emergency Contact

Emergency Contact Name *

Relationship *

Emergency Contact Phone *

Primary Insurance

Insurance Company *

Member ID *

Group ID

Insurance Phone

Policy Holder Name

Policy Holder Date of Birth

Relationship to Policy Holder

Secondary Insurance (if applicable)

Insurance Company

Member ID

Group ID

Insurance Phone

Referring & Primary Care Physicians

Referring Physician

Practice / Group

Referring Physician Phone

Referring Physician Fax

Primary Care Physician

Primary Care Physician Phone

Reason for Visit / Chief Complaint *

Current Medications (name, dose, frequency)

Allergies (medication, food, environmental)

Past Medical History (diagnoses, chronic conditions)

Past Surgical History

Family History (kidney disease, diabetes, hypertension, cancer)

Social History (tobacco, alcohol, occupation, exercise)

Southern California Kidney Associates — Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Our Responsibilities

We are required by law to maintain the privacy of your protected health information (PHI), to provide you with notice of our legal duties and privacy practices, and to notify you following a breach of unsecured PHI.

How We May Use and Disclose Your Health Information

Treatment: We may use and disclose your PHI to provide, coordinate, or manage your health care and related services.
Payment: We may use and disclose your PHI to obtain payment for services we provide to you.
Health Care Operations: We may use and disclose your PHI in connection with our health care operations, including quality assessment, training, and business management.
As Required by Law: We will disclose your PHI when required to do so by federal, state, or local law.
Public Health Activities: We may disclose your PHI for public health activities such as reporting communicable diseases.

Your Rights

Right to inspect and copy your health information
Right to request an amendment to your health information
Right to request restrictions on how we use or disclose your PHI
Right to request confidential communications
Right to an accounting of disclosures
Right to a paper copy of this notice

Complaints

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.

I acknowledge that I have received, read, and understand the Notice of Privacy Practices of Southern California Kidney Associates.

Patient / Guardian Signature (type full name) *

Date *

This authorization allows Southern California Kidney Associates to obtain your medical records from another provider. You may revoke this authorization at any time by notifying us in writing.

Release Records FROM — Provider / Facility Name *

Address

Phone / Fax

Records Requested

Purpose of Release

Patient / Guardian Signature (type full name) *

Date *

Consent to Communicate via Email

Email communication is not a completely secure or confidential method of communication. Email messages may be copied, forwarded, stored, or intercepted by third parties. By signing below, you consent to communicate with Southern California Kidney Associates via email for non-urgent matters such as appointment reminders, general health information, and follow-up questions.

Please understand:

Email is not appropriate for urgent or emergency medical issues. Call 911 or go to the nearest emergency room for emergencies.
We will make reasonable efforts to respond to emails within 2 business days.
Email communications may become part of your medical record.
You may withdraw this consent at any time by notifying our office in writing.

Patient Name *

Email Address to Use for Communications *

I consent to receive non-urgent communications from Southern California Kidney Associates via the email address provided above. I understand the risks associated with email communication and agree to the terms described above.

Patient / Guardian Signature (type full name) *

Date *

By submitting this form you confirm that all information provided is accurate and complete to the best of your knowledge.