1. Patient Registration

2. Insurance Information

3. Emergency Contact and PHI Permission

4. Consent for Treatment and Assignment of Benefits

I consent to evaluation, medical treatment, procedures, testing, and care provided by the clinic care team. I authorize the release of information needed to process insurance claims and assign insurance benefits to the clinic when applicable.

5. Patient Financial Responsibility

I understand that I am responsible for providing current insurance information at each visit. I am responsible for applicable copays, coinsurance, deductibles, non-covered services, and balances not paid by my insurance plan, unless prohibited by law or contract.

If a health plan denies coverage or determines that a service is not covered, I may be financially responsible for the service, subject to applicable federal and California law. This policy does not waive any patient protections under Medicare, Medi-Cal, managed care contracts, surprise billing laws, or other applicable law.

California medical debt notice: A holder of this medical debt contract is prohibited by California Civil Code Section 1785.27 from furnishing information related to this debt to a consumer credit reporting agency.

6. Cancellation / No-Show Policy

Please cancel or reschedule at least 48 hours before your appointment whenever possible. If an appointment is not cancelled at least 48 hours in advance, a $25.00 fee may be charged. This fee is not covered by insurance. The clinic may waive the fee at its discretion for emergencies or circumstances outside the patient control.

7. Open Payments Notice

The Open Payments database is a federal tool that may be used to search payments made by drug and medical device companies to physicians and teaching hospitals. It can be accessed at https://openpaymentsdata.cms.gov.

8. HIPAA / Privacy Practices Acknowledgment

I acknowledge that I have been offered or received the My Chula Vista Doctors Medical Clinic Notice of Privacy Practices. I understand that the clinic may use and disclose protected health information (PHI) for treatment, payment, and health care operations, and as otherwise permitted or required by law.

I understand that I have rights related to my PHI, including the right to request access or copies, request amendments, request restrictions, request confidential communications, request an accounting of certain disclosures, obtain a paper copy of the Notice of Privacy Practices, and file a complaint without retaliation.

Email and text messages may not be fully secure. I may request alternate communication methods in writing.

9. Communication Preferences / Restrictions

10. Medical History Questionnaire