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PATIENT REGISTRATION FORMS

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New Patient Registration

 

Medical Records Request

 

HIPAA Notice of Privacy Practices

 

Notice of Privacy Practices Acknowledgement of Receipt

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Patient Authorization To Discuss Protected Health Information

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

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DENTAL REGISTRATION FORMS

 Pediatric Dental Form

 

Adult Dental Form

 

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

 

HEALTH PLANS WE ACCEPT

(but not limited to)

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  • Indian Health Services

  • Medicare

  • Medical

  • California Health & Wellness

  • Covered California

  • Anthem Blue Cross Managed Care

  • Anthem Blue Cross

  • Blue Shield

  • Most private insurance companies

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

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

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