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  • New Patient Registration

    Please complete the following forms if you are registering a new patient. Please be sure to verify that we accept your insurance prior to filling out this form and have your insurance card accessible.

  • Patient Information

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  • Contact Information


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  • Electronic Communication Consent

  • In Case of Emergency

    Please provide the contact information of a family member, friend or relative. This is not your physician. If you wish to add an additional emergency contact, please let us know at your next appointment.

  • Insurance Information

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  • Demographics

  • Pharmacy Information

  • Insurance Assignment and Authorization

    I hereby authorize Edinger Medical Group to furnish information to insurance carriers concerning my illness and treatments. I hereby assign all payments for medical services rendered to my dependents or myself to Edinger Medical Group. I understand that I am responsible for any amount not covered by insurance.

  • Pharmacy History Authorization

    I hereby authorize the physicians of Edinger Medical Group to review my medication history as prescribed by other physicians.
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  • Current and Past Medical History

    Please check the box of any of the following illnesses and medical problems you have or have had and indicate the year when each started. If you are not certain when an illness started, enter an approximate year.
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  • Prior Hospitalization and Surgeries

    Please remember to click on "Save and Add Row" after each input to save your response for the following questions.

  • Medication

    Please remember to click on "Save and Add Row" after each input to save your response for the following questions.

  • Menstrual History

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  • Family History

    If any blood relative has suffered any of the following - please indicate which relative.
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  • Health Risk Factors

  • Other

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  • Patient Financial Policy and Agreement

  • Patient Financial Policy

    Edinger Medical Group (EMG) is committed to serving your healthcare needs. Please understand payment of your bill is considered part of your healthcare relationship with our medical group and physicians. The following is a statement of EMG’s Financial Policy. EMG requires you to read and agree to the financial policy prior to receiving treatment.

    WE ACCEPT CASH, CHECKS, VISA, MASTERCARD, DISCOVER AND AMERICAN EXPRESS

  • INSURANCE BILLING
    Your insurance policy is a contract between you and your health insurance company. We are not a party to that contract. It is your responsibility to know your benefits and how they will apply to the treatment you receive. If your insurance company has not paid your account in full within 60 days, the balance will be transferred to you and/or the guarantor listed on the Patient information form. All patients are responsible for their co-payment, co-insurance, unmet deductible and cost of non-covered services at time of visit.

  • CONTRACTED HMO PLANS
    All co-pays must be satisfied at every visit. Due to contractual and uniform compliance issues with your insurance company, there are no exceptions to the policy of collecting co-pays at every visit.

  • CONTRACTED PPO PLANS
    We will bill your insurance company as a courtesy. All co-pays, co-insurance, unmet deductible, and cost of non-covered services will be collected at the time of the visit. Any remaining balances due after contract adjustments and health plan payments are your responsibility. You will receive a statement for this remaining financial responsibility. All patient balances are due within 30 days of our statement date.

  • OUT OF NETWORK PLANS
    For patients with plans that we are Out of Network. All services must be paid in full at the time of the visit/treatment. Our offices will provide you with an estimate of the cost of treatment before the visit.

  • CASH PATIENTS
    For cash patients. All services must be paid in full at time of visit/treatment. Our offices will provide you with an estimate of the cost of treatment before the visit.

     

  • PAST DUE ACCOUNT BALANCES
    Patients with an outstanding balance deemed past due (90 days) must plan for payment prior to scheduling any future appointments. Should your account become seriously past due, it will affect scheduling of any new appointments and refill of medications in a timely manner.

     

  • SUSPENDED ACCOUNTS AND TERMINATION OF CARE:
    In the event outstanding balances are not paid within 120 days, your patient status will be suspended. Once suspended, your provider/patient relationship with the medical group will be terminated, and you will need to receive care and necessary medication refills elsewhere.

  • REPORTING OF DELINQUENT ACCOUNTS TO CREDIT AGENCIES:
    If a patient account balance becomes delinquent and the patient account is suspended, that delinquent balance will be reported to national credit agencies. This may affect your current and long term credit status adversely. These delinquent balances will remain in affect with these credit bureaus indefinitely in the future until your overdue balance is paid.

  • PATIENT REFUNDS
    The following criteria must be met prior to issuing a patient refund:
    No outstanding insurance claims on the patient account.
    No outstanding patient balance on the patient account.

  • RETURNED CHECKS
    A $25.00 fee will be charged for any returned checks.

    I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance on my EMG account for any professional services rendered. I have read the above EMG Patient Financial Policy, agree to abide by it, and have provided EMG with true and correct insurance information. I will notify EMG of any change in my health insurance coverage.

  • Patient Financial Policy Agreement

    By signing this form, I acknowledge that I have read and hereby agree with the terms and conditions in the Patient Financial Policy.
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  • Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations

  • Use and Disclosure

    I, {name}, understand that as part of my health care, Edinger Medical Group originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:

    • A basis for planning my care and treatment,
    • A means of communication among the many health professionals who contribute to my care,
    • A source of information for applying my diagnosis and surgical information to my bill,
    • A means by which a third-party payer can verify that services billed were actually provided, and
    • A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

    I understand and will be provided with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

    • The right to review the notice prior to signing this consent, and
    • The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations.

    I understand that Edinger Medical Group is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

    I understand that as part of this organization's treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax.

  • I wish to share my electronic medical records in efforts to assist me with current or future care needs:

    I understand that I have the right to revoke this privilege in writing.
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  • Authorization for Use or Disclosure of Health Information

    Please indicate whether you would like your protected health information to be released to or from Edinger Medical Group. Completion of this document authorizes the disclosure and/or use of individually identifiable health information, as set forth below, consistent with California and Federal law concerning the privacy of such information. Failure to provide all information requested may invalidate this Authorization.

  • Authorization for Designated Physician/Facility (NOT EMG) to Release Protected Health Information

  • I authorize the release of my health information FROM:

  • To be released TO the following recipient (organization that will RECEIVE your information):

    Edinger Medical Group
    900 Talbert Avenue, Suites 301-302
    Fountain Valley, CA 92708

  • Health Information to be Released for the Following Dates

  • Part B: In compliance with California Statutes, which require special permission to release otherwise privileged information, please INITIAL next to the records that you want released: (separate specific authorization required)

  • Health Information Release Authorization

  • Purpose or Need for Disclosure

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  • If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may be disclosed and may no longer be protected. California law prohibits recipients of your health information from redisclosing such information except with your written authorization or as specifically required or permitted by law.

  • Additional Information Regarding Release of Health Information

  • Edinger Medical Group recognizes the patient's right of confidentiality of their health information under federal privacy regulations and California law. The patient should be aware of the following information when requesting or releasing health information.

    Right to Refuse to Sign this Authorization: This authorization is voluntary. Refusal to sign will not affect the patient's ability to receive treatment or payment of claims.

    Right to Inspect or Receive a Copy of Health Information to be Used or Disclosed: A patient has the right to inspect or obtain a copy of the health information they have authorized to be used or disclosed by signing this Authorization form.

    Right to Receive a Copy of this Authorization: A patient has the right to revoke his authorization at any time by giving written notice of revocation to the Privacy Officer. Revocation of this authorization WILL NOT affect any action taken in reliance of this authorization before receipt of the written notice of revocation.

    Multiple Releases of Information: A patient may request multiple releases of the information stated on the Authorization form. However, all releases based on this form are limited to records dated up to and including the date of the patient's signature. A new authorization is necessary for release of information for care provided after the date of the patient's signature, UNLESS the authorization specifically states that SPECIFIC RECORDS that will be generated in the future may be released, for example, "future records of a specific test" or "future records of specific clinic appointment."

    Who May Sign this Authorization

    1. Generally, all patients 18 years of age and older must sign for release of their own health information unless the following conditions apply:
      • The patient is incompetent
      • The patient is disabled and cannot sign the form
      • The patient is deceased (a surviving spouse or personal representative of the estate may sign. If there is no surviving spouse or representative, then an adult member of the immediate family may sign)
      IMPORTANT: With very few exceptions, if the patient is age 18 or older, parents' signatures ARE NOT acceptable.
    2. All persons signing for release of health information on behalf of the patient must state their relationship to the patient and provide legal proof of legal authority of their capacity to act for the patient.
    3. Minors: Patients less than 18 years of age must sign for release of health information in the following cases:
      • Alcohol or other drug related abuse treatment: age 12 or older
      • Mental health treatment: age 12 or older may consent to release of records without parental consent
      • HIV test results: age 12 or older
      • Emancipate minors who are married or in the military

    Fees for Records: Copies of a patient's medical record sent directly to another physician or medical facility will be made generally at no charge; however, if many requests are made, a copying fee may be applied as allowed by California law.

  • Edinger Medical Group Medical Records
    Email: medicalrecords@edingermedicalgroup.com
    Fax: 714-965-2595

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