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PATIENT REGISTRATION FORMS

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

Dental forms can be emailed to: mathiesen.dental@crihb.org

Primary Care

New Patient Registration Packet

New Pediatric Registration Packet

Wellness Center

New Wellness Center Registration Packet

Dental Clinic

New Pediatric Dental Registration Form

New Adult Dental Registration Form

Acupuncture Clinic

New Acupuncture Registration Packet

Other Forms

Medical Records Request – Primary Care & Dental

Medical Records Request – SUD and Behavioral Health

HIPAA Notice of Privacy Practices

Notice of Privacy Practices Acknowledgement of Receipt

Patient Authorization To Discuss Protected Health Information

HEALTH PLANS WE ACCEPT

Our Primary Care Clinic is currently accepting:

Indian Health Services

Medicare

Medi-Cal

Health Net Medi-Cal

Anthem Blue Cross Managed Medicare & Medi-Cal

Our Dermatology, Behavioral Health, Red Feather, Acupuncture, and Same Day Walk-In Clinics are currently accepting:

All Health Plans listed above, plus:

Anthem Blue Cross

Blue Shield

Cigna/Evernorth

Aetna

TriCare

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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