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

New Patient Packet

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

NP 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 be contacted by the office.  

Permission to Relay Info (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 (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

Request for Records

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

Release of Records (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

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