250 East Yale Loop #204, Irvine, California 92604
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.
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.
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.
Notice of Privacy Practices (NPP)
Notice of Privacy Practices (NPP)
Notice of Privacy Practices (NPP)
How your PHI (protected health information) is used shared.
Acknowledgement - NPP
Notice of Privacy Practices (NPP)
Acknowledgement - NPP
Acknowledgement that you have read and understood our Notice of Privacy Practices.
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.
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.
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.)
New Patient Packet
Required paperwork for all New Patients and any patient not seen in the office in the last 3 years.
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.
Annual Wellness Form - Age 65+
To be completed yearly by all patients age 65 and over and reviewed during your Annual Wellness exam.
Notice of Privacy Practices (NPP)
How your PHI (protected health information) is used.
Acknowledgement - Notice of Privacy Practices
Acknowledgement that you have read and understood our Notice of Privacy Practices.
Health History Form (all ages)
To be updated yearly, usually for your annual exam / physical exam.
Request for Records
Signed consent is needed for other doctors offices and hospitals to send their records to our office.
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.
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.
Comprehensive Care Center of Irvine
250 East Yale Loop #204, Irvine, California 92604, United States
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