Your new-patient forms, explained

Getting forms

At check-in, or call (310) 326-2161 to request them

Formats

Large print or Korean on request

Returning forms

Bring them to your visit. Please don’t email completed forms.

Questions

Ask us about any form before you sign

Forms for new patients

At your first visit, we ask new patients to complete a few forms. Current forms are provided at check-in, or you can call (310) 326-2161 to request them. If you would like help reading or filling out a form, just ask our front desk.

Completing your forms

1. Get the forms

   Pick them up at check-in, or call us to request them.

2. Take your time

   Read each form. Ask us about anything that isn’t clear.

3. Bring them in

   Bring completed forms to your visit with your photo ID and insurance card.

4. Keep a copy

   You may ask for a copy of any form you sign.

Patient information form

This form collects the details we need to care for you and reach you: your name, date of birth, address, phone numbers, emergency contact and insurance information. For patients under 18, it also asks about the parent or guardian responsible for the account. Our form is printed in English and Korean.

The form also has spaces for a Social Security number and a driver’s license number. If you would rather not share these, please ask us whether you can leave them blank. The Federal Trade Commission suggests asking whether an office can use a different identifier or only the last four digits of your Social Security number.

Acknowledgment of our Notice of Privacy Practices

Our Notice of Privacy Practices explains how we may use and share your health information and describes your privacy rights. We will ask you to sign a short form confirming that you received the notice.

You can read the notice on our website at any time, and you have the right to ask for a paper copy.

Physician–patient arbitration agreement

Some patients are also asked to sign a physician–patient arbitration agreement. This is an agreement that any dispute about medical malpractice would be decided by neutral arbitration instead of by a lawsuit in court. By signing it, you give up the right to a jury or court trial for that kind of dispute.

California law requires specific wording for the arbitration section of this agreement and a notice in bold red type just above the signature line. Under California law, you can cancel the agreement by giving written notice within 30 days after you sign it (Code of Civil Procedure § 1295).

Please take your time to read the agreement, and ask us any questions before you sign.

Keeping your information private

Please don’t email completed forms, photos of your ID or insurance card, or medical details. Regular email may not be secure. Bring your forms to your visit, or call us if you have questions.

If you are coming to us from another doctor, that office can tell you how to send your records to us. Our fax number is (310) 534-5026.

Forms in large print or Korean

Ask for a large-print or Korean-language copy of any form when you call or check in. We speak English and Korean (한국어). Japanese (日本語) assistance — please call ahead. Free interpreter services are available in any language. See our language assistance notice and accessibility statement.