New Patient Intake Forms
New Patient Paperwork is completed via our patient portal. Please follow the link to the patient portal
PLEASE NOTE: New patient appointments are only confirmed upon receipt of your new patient intake paperwork. Paperwork must be completed and received by our office no later than 1 week prior to your appointment or your appointment will be canceled and you will be requested to reschedule.
Records Request Form
Option 1: ONLINE REQUEST (Records sent to patient only)
You may sign up for a free Health Gorilla account online to both request & receive records from our office ($1 fee from Health Gorilla per records request). Simply go to Health Gorilla and follow these Step-By-Step Instructions to complete their records request process. Once completed, a signed records request form wiIl be sent to us electronically, no need for mail in forms! We will then supply you with the requested records via the Health Gorilla Portal. PLEASE NOTE: You can ONLY request records be sent to you via this method. For any other individual you wish to authorize to receive your records or protected health information you must fill out our mail in office form and follow the directions below for Option 2.
Option 2 Mail-In Form:
Please use this form if you wish to receive a copy of your medical chart, or a limited part of your medical chart. You may use this form to allow us to send records to your other care providers, to yourself, or to another designated 3rd party. Please note that for paper copies of records we charge $.25/page plus a $15 processing fee and shipping if they are mailed (no shipping charge if they are picked up). You may also elect to receive them on a USB, and will be charged $15 for the USB plus the cost of shipping (no shipping charge if they are picked up). Due to the private nature of the information contained in your medical files, all records that are mailed are done so with Recipient Signature Required. This means the person they are released to will be the person who must sign for the package. At this time there is no fee for faxing your records to you or a third party.
This form must be returned as a hard copy original to our office. You may mail it to our Mail Only address at 448 Ignacio Blvd, #294, Novato CA 94949, or drop it off at our office either in-person, through messenger service or other means on Tuesdays when our office is open (please call to arrange a time for drop off)
COSTS: Fax=Free, Share via Health Gorilla is free (Records Request form through Health Gorilla is $1), hard copies are $.25/page plus handling fee of $15 ( if mailed shipping fees will be charged), USB $15 + shipping & handling (PLEASE NOTE: Mailed copies must be sent restricted delivery signature required only to the named recipient. This may incur additional shipping fees.)
Medical Release Form (Non-Provider)
Please download and return this form to our office if you wish to authorize another individual (non-provider) to have access to your records. Due to the nature of the release we require these forms be completed, signed and a hard copy provided to us. You may have it dropped at our office or if you wish to mail it to us please mail to 448 Ignacio Blvd, #294, Novato CA 94949 (Mail-Only address).
Fax=Free, hard copies are $.25/page plus handling fee of $15 ( if mailed shipping fees will be charged), USB $15 + shipping & handling (Mailed copies must be sent restricted delivery signature required only to the named recipient. This may incur additional shipping fees.)
