Forms For Patients:
- Release of Medical Records To Specific Individual or Entity
- Release of Medical Records To Insurance Company
- Release of Billing Information Form
- Request for UCLA Records to be Sent to Dr Stein
- Health History Questionnaire
- HIPAA Privacy Notice
Forms For Financial Guarantors
- These forms are to be used if patients have a guarantor paying for their services. Guarantors should FAX completed forms to 888-959-0148 at least 48 business days before the patient’s initial visit. Patients need to make sure they complete the authorization to release billing informationto the guarantor, also found in the initial paperwork.
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