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Patient Registration & Consent Forms

We would like to make your visit as efficient as we can. 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 and Seniors

  • Registration Form (English and Spanish) >
  • Health Questionnaire >
  • Health Questionnaire (Español) >
  • General Consent for Medical Treatment/Healthcare (English) >
  • General Consent for Medical Treatment/Healthcare (Español) >
  • Financial Policy - (English and Spanish) >
  • Medicare Annual Wellness Visit Check-In Form >
  • Medicare Annual Wellness Visit Check-In Form (Español) >

  • *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.

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    For Minors

    Parent(s) who are unable to bring their child(ren) in for their medical care and who have asked a responsible adult to do so, must provide written authorization for this to occur. For patient convenience, Sansum Clinic provides an "Authorization for Agent to Consent to Medical Treatment of a Minor". Note: Parent or legal guardian must be present for all child immunizations.

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    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.

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    Radiology Forms

    This form is used to request copies of CT scans, mammograms, MRIs, PETs, X-Rays and other radiologic records.

    Authorization to Release Radiologic Records >

    The completed authorization form should be sent to:

    Health Information Services (HIS)
    c/o Release of Information Department
    89 S. Patterson Ave.
    Santa Barbara, CA 93111

    Radiology Forms >

    *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.

    Back To Top >

    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 situations that may apply to you.

    Consent for Proxy Access to MyChart

    Adults may have a family member, loved one or caregiver who they would like to grant access to their MyChart Account. To do this, sign in to your own MyChart account and click the My Family’s Records link on the My Account tab. Then click the Grant an adult access to your record link. Fill out the form and click Submit Request. You and your proxy will be contacted within 2 business days to complete the request. In cases of diminished capacity of the patient, the proxy can request access using the Request for Proxy Access to MyChart form. The patient MUST have legal documentation of the proxy’s right to access their medical records on file (i.e. durable power of attorney).

    Download: Request for Proxy Access to MyChart (English) >

    Release of Clinical Information

    Adults may have a family member, loved one or caregiver who makes their appointments or calls for medical concerns on their behalf. These representatives must be identified by the patient and documented in the patient records so our medical and support staff can provide medical information to them. For patient convenience, Sansum Clinic provides "Consent to Disclose Protected Health Information to a Designated Patient Representative" form.

    Download: Consent to Disclose Protected Health Information to a Designated Patient Representative (English) >
    Download: Consent to Disclose Protected Health Information to a Designated Patient Representative (Español) >

    Release of Billing Information

    Patients may have someone assisting them with their financial matters. These representatives must be identified by the patient and documented in the patient records so our medical and support staff can provide billing information to them. The completion of the "Patient Consent for Release of Billing Information" form will permit our Billing Staff to speak directly with the person regarding your financial matters with Sansum Clinic.

    Download: Patient Consent for Release of Billing Information >

    Medical Release Forms

    This form, which is also available in Spanish, is necessary for the inspection or copying of a patient’s medical records. Release of patient medical information requires completing a "Authorization for Use/Disclosure of Protected Health Information" form. There is no charge for forwarding health information to other providers including those outside Sansum Clinic.

    Download - English: Authorization for Use/Disclosure of Protected Health Information (English) >Download - Spanish: Authorization for Use/Disclosure of Protected Health Information (Español) >