Forms & Insurance | Mathiesen Memorial Health Clinic | United States

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PATIENT REGISTRATION FORMS

New Patient Registration

Medical Records Request

HIPAA Notice of Privacy Practices

Notice of Privacy Practices Acknowledgement of Receipt

Patient Authorization To Discuss Protected Health Information

All forms can be emailed to: mathiesen.clinic@crihb.org

HEALTH PLANS WE ACCEPT

(but not limited to)

Indian Health Services
Medicare
Medical
California Health & Wellness
Covered California
Anthem Blue Cross Managed Care
Anthem Blue Cross
Blue Shield
Most private insurance companies

Please Call our Administration / Financial office for any billing & financial questions: 209-984-4827

Not covered by any of these plans? Contact us and we will find the best solution to suit you.

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