Welcome to our practice. Please fill out the following demographic and insurance information. This confidential form will be electronically entered into our office records. Please note that * fields are required and the form will not submit until all required information is entered. If the * field is not applicable please enter none or NA to prevent from getting a very annoying error message when you are done. If you have any questions please call us at 805-922-5749.
Date of Birth:
We have a secure message center that allows you to communicate with us via our secure website portal. To enroll you we need your email address.
Work/Employer/Social Security Information
Spouse/Significant Other/Caregiver Information
Emergency Contact Information
Release of information and Durable Power of Attorney.
Insurance Information. PLEASE BRING IN YOUR INSURANCE CARD WITH YOU FOR US TO COPY.
Financial and Medical Records Policy.
All office and hospital charges will be billed to your primary and secondary insurance companies. Patients receiving insurance payments must forward those payments to this office.
Insurance inquires regarding payment is your responsibility unless we are a contracted provider for your insurance.
We are required to collect all co payments for office visits at the time of the visit.
Patient Responsibility Statement
Payment in full is required for balances remaining after both primary and secondary insurance companies have made payment. If these payments present a hardship, payment arrangements must be made.
You must call this office to make payment arrangements in order to avoid collection action..
Release of Medical Records
Patients must sign a records release authorization. There is a $.25 per page copying fee for records released to patients. This fee is waived for records going directly to another physicians office.
Records will be released within 15 business days from the time of the request.
We will notify you if your insurance company requests your records.
Assignment of Medical Information and Benefits:
I authorize Dr. Bruce A. Ourieff, MD Inc to release to my insurance carrier any information required to complete the processing of an insurance claim for payment.
I have read the above financial and record procedures guidelines and I agree to there terms.
Medicare Life Time Assignment Authorization.
I request that payment of Medicare benefits be made to Bruce A. Ourieff, MD, Inc on my behalf for any services furnished to me by Bruce A. Ourieff, MD Inc. I authorize any medical information about me to be released to the Center for Medicare Services (CMS) and its agents as is needed to determine benefits or benefits payable for related services.
I request the payment of authorized Medigap (secondary insurance) benefits be made to Bruce A. Ourieff, MD, Inc on my behalf for any services furnished to me by Bruce A. Ourieff, MD, Inc.. I authorize medical information about me be released to my secondary insurance when needed to determine these benefits or the benefits payable for related services until this authorization is revoked.