Filling out these forms ahead of time will help save time when you come for your appointment. All the forms below are available in Adobe PDF format. If you haven't installed Acrobat® Reader® on your computer, in order to view and print these forms, please download and install the Acrobat Reader from the Adobe website.
- Patient Information
- Health History
- Eligibility Guarantee/Patient Financial Responsibility
- Notice of Privacy Practices and HIPAA
- Prescription Information
- Office Visit Cancellation Policy
We are committed to providing the highest level of medical care to our patients. To ensure that our patients fully understand our billing process, we ask that you read and sign the form listed below:
Patients are seen in the office by appointment only. Please call (310) 652-9162 to make an appointment. For your initial visit we request you to download and fill out the forms in the Forms section. If this is not possible please arrive in the office fifteen minutes early to fill out necessary paperwork.
Cancellation/ No Show Policy for Doctor Appointment
We normally make a courtesy confirmation call to remind you of upcoming appointments. We have a 24 hour phone message system with voicemail attendant so that you may conveniently and promptly cancel appointments that you find you are now unable to keep.
We consider any cancellation made less than 24 hours prior to your scheduled appointment a short notice cancellation, since this makes it difficult to schedule another patient to fill the appointment time that had been reserved for you. If you do not keep a scheduled appointment and fail to notify us in advance, or if you notify us with only a short notice as defined above, we will impose a $50.00 charge against your account.
Thank you in advance for your understanding. We hope that this policy will help serve all of our patients promptly and efficiently.
We contract with many insurance plans and accept cash, check, Mastercard, Visa, and American Express. Payment of all Co-Pays and Deductibles must be made at the time of all visits. If we do not participate with your insurance company, full payment is expected at the time of any office visit. In addition to Medicare, we accept most private insurances that are non HMO.
- American Association of Kidney Patients (AAKP)
- American Kidney Fund (AKF)
- American Society of Pediatric Nephrology
- National Kidney Foundation (NKF)
- Dialysis & Transplantation
- Hypertension, Dialysis, and Clinical Nephrology (HDCN)
- Kidney & Urology Foundation of America
- Kidney School
- Life Options Rehabilitation Program
- Kidney & Urologic Diseases
- Nephron Information Center
- Nephro World
- Renal Support Network
- U.S. Renal Data System (USRDS)
- American Diabetes Association