Sansum Clinic
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We would like to make your visit as efficient as we can. If you would like to fill out your patient registration information in advance, please visit the links below to print the appropriate forms, fill them out in English or Spanish, and bring them with you to your appointment.*

If you have questions or need assistance, please call our Pre-Registration Department at (805) 681-1840.

For Adults

Health Questionnaire

     Cuestionario Médico (Health Questionnaire – Spanish)

General Consent for Medical Treatment

     Consentimiento General Tratamiento Médica

Patient Registration/Financial Policy

     Registración Del Paciente/Política Financiera

For Minors

Pediatric Health History

     Coming Soon (Pediatric Health History – Spanish)

General Consent for Medical Treatment

     Consentimiento General Tratamiento Médica

Patient Registration/Financial Policy

     Registración Del Paciente/Política Financiera

For Seniors

Health Questionnaire

     Cuestionario Médico (Health Questionnaire – Spanish)

General Consent for Medical Treatment

     Consentimiento General Tratamiento Médica

Patient Registration/Financial Policy

     Registración Del Paciente/Política Financiera

*Submitting preliminary healthcare or insurance information or making an appointment with the practice does not establish a physician-patient relationship. That relationship is not created until the office visit has been completed.

Additional Consent and Authorization Forms

There are circumstances when a patient may want someone else to be able to obtain or provide medical or financial information on their behalf. In keeping with HIPAA (Health Insurance Portability and Accountability Act) privacy and security requirements, special consents and authorizations are available at Registration for your convenience or you may download them below and bring the completed forms with you when you arrive for your appointment.

Here are some additional forms that may apply to you. Click here to learn more about these forms.

Authorization for Agent to Consent to Medical Treatment of a Minor

Consent to Disclose Protected Health Information to a Designated Patient Representative

Patient Consent for Release of Billing Information

Registration for Proxy Access to MyChart**

Authorization for Use/Disclosure of Protected Health Information (English)
Authorization for Use/Disclosure of Protected Health Information (Espanol)

*Submitting preliminary healthcare or insurance information or making an appointment with the practice does not establish a physician-patient relationship. That relationship is not created until the office visit has been completed.

**NOTE: This form must be completed and presented in-person to our Release of Information (ROI) window located at:

Health Information Services (HIS)
Sansum Clinic
317 W. Pueblo Street, Lower Level
Santa Barbara, CA
(805) 898-3188

Sansum Clinic
Providing innovative healthcare services in Santa Barbara County for more than 90 years.
1-800-472-6786

 

© 2013 Sansum Clinic

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