250 East Yale Loop #204, Irvine, California 92604

(949) 732-3530

  • Home
  • Our Providers
    • Amanda A. Binns, M.D.
    • Kalena K. Hwang, M.D.
    • Kelly K. Wong, M.D.
    • Katherine Matsumoto, FNP
  • Patient Info
    • Patient Information
    • Forms
    • Links
    • Insurance
  • Contact Us
  • Patient Portal
  • More
    • Home
    • Our Providers
      • Amanda A. Binns, M.D.
      • Kalena K. Hwang, M.D.
      • Kelly K. Wong, M.D.
      • Katherine Matsumoto, FNP
    • Patient Info
      • Patient Information
      • Forms
      • Links
      • Insurance
    • Contact Us
    • Patient Portal

(949) 732-3530

  • Home
  • Our Providers
    • Amanda A. Binns, M.D.
    • Kalena K. Hwang, M.D.
    • Kelly K. Wong, M.D.
    • Katherine Matsumoto, FNP
  • Patient Info
    • Patient Information
    • Forms
    • Links
    • Insurance
  • Contact Us
  • Patient Portal
Comprehensive Care Center of Irvine

FORMS

New Patient Packet

Annual Wellness Form - age 65+

Permission to Relay

Required paperwork for all New Patients.  Packet includes Patient Demographics, NPP, Permission to Relay, Health History and Request for Records forms. 

NEW PATIENT PACKET

Permission to Relay

Annual Wellness Form - age 65+

Permission to Relay

You can list any person(s) you would like us to be able to discuss with or release your medical information to and list the best method for you to contacted by the office. 

PERMISSION TO RELAY

Annual Wellness Form - age 65+

Annual Wellness Form - age 65+

Notice of Privacy Practices (NPP)

 To be completed yearly by all patients age 65 and over and reviewed during your Annual Wellness exam. 


ANNUAL WELLNESS - 65+

Notice of Privacy Practices (NPP)

Notice of Privacy Practices (NPP)

Notice of Privacy Practices (NPP)

 How your PHI (protected health information) is used shared. 


NPP

Acknowledgement - NPP

Notice of Privacy Practices (NPP)

Acknowledgement - NPP

 Acknowledgement that you have read and understood our Notice of Privacy Practices. 

ACKNOWLEDGEMENT - NPP

Request for Records

Notice of Privacy Practices (NPP)

Acknowledgement - NPP

 Signed consent is needed for other doctors offices and hospitals to send their records to our office. 

RECORDS REQUEST

Authorization to Release Records

Authorization to Release Records

Authorization to Release Records

 Signed consent is required to have records sent from CCCI to your new PCP, Specialist or yourself. Fill out and send to the office. 



AUTH TO RELEASE RECORDS

POLST Form

Authorization to Release Records

Authorization to Release Records

  Physician Orders for Life Sustaining Treatment (POLST) can help make sure you get the care you want, and also protect you from getting medical treatments you DO NOT want. (To be completed on PINK paper.)

POLST FORM

New Patient Packet

Required paperwork for all New Patients and any patient not seen in the office in the last 3 years.

New Patient Packet (pdf)Download

Permission to Relay Information

  To be HIPAA compliant, you can list any person(s) you would like us to be able to discuss with or release your medical information to and list the best method for you to contacted by the office.  

Permission to Relay Information (pdf)Download

Annual Wellness Form - Age 65+

To be completed yearly by all patients age 65 and over and reviewed during your Annual Wellness exam.

Annual Wellness Form - 65+ (pdf)Download

Notice of Privacy Practices (NPP)

How your PHI (protected health information) is used.

Notice of Privacy Practices - READ ONLY (pdf)Download

Acknowledgement - Notice of Privacy Practices

Acknowledgement that you have read and understood our Notice of Privacy Practices.

Notice of Privacy Practices - Acknowledgement (pdf)Download

Health History Form (all ages)

 To be updated yearly, usually for your annual exam / physical exam. 

Health Questionnaire (*Not the Annual Wellness Form - Age 65+) (pdf)Download

Request for Records

Signed consent is needed for other doctors offices and hospitals to send their records to our office. 

Records Request (pdf)Download

Authorization to Release Records

Signed consent is required to have records sent from CCCI to your new PCP, Specialist or yourself. Fill out and send to the office.

Authorization to Release Records (pdf)Download

POLST Form

 Physician Orders for Life Sustaining Treatment (POLST) is a medical order that helps give people with serious illness more control over their care during a medical emergency. POLST can help make sure you get the care you want, and also protect you from getting medical treatments you DO NOT want. 

To be completed on PINK paper.

POLST Form - PRINT ON PINK PAPER (pdf)Download

Comprehensive Care Center of Irvine

250 East Yale Loop #204, Irvine, California 92604, United States

(949) 732-3530

Copyright © 2023 Comprehensive Care Center of Irvine - All Rights Reserved.

Have an Amazing Day!

Cookie Policy

This website uses cookies. By continuing to use this site, you accept our use of cookies.

Accept & Close