Forms to Download
All of the forms below can be electronically uploaded, faxed, mailed or dropped off to the San Francisco office, Mill Valley office or Billing Office .
We cannot accept electronic signatures on forms that require a signature. If you are submitting the forms via our website, please print the form, sign it, scan it and then upload the form. Or you can submit the form without a signature and we will hold onto to it until your next visit and ask you to sign it at that time.
To view the below PDF files, you can use Adobe’s Acrobat Reader.
New Patient Forms
If you are coming into our office for a visit for the first time, please electronically complete the forms. If a sibling already comes to our practice, we still need these forms completed for the new patient. Please remember to bring an insurance card and a photo ID as well to your first visit.
School/Camp/Sports Permission Form
If you are submitting a form to be completed by one of our physicians, please fill out the permission form and submit it with the form you need completed by your physician. This will assist us in accurately completing the form you are submitting to us. Please make sure you have completed all sections of your form that are supposed to be filled out by the parent or student before submitting your form to our office.
There is a $20 fee for all forms that the physicians need to complete. Due to the quantity of forms we receive, there is usually a five day turnaround time. If the form is needed sooner, the fee to complete it within 24 hours is $40.
Record Release Authorization Form
If you would like to request a copy of a patient’s records for yourself or to be transferred to another doctor, please complete the release form and submit it to the appropriate office with $25.00. If the patient is over 18 years of age, he/she must sign the release themself.
Immunization Record Release Request Form
If you would like ONLY a copy of the patient’s immunization record, you can download it from your patient portal. Or please complete and submit the release form to the appropriate office. There is no fee for this.
Vaccine Administration Permission Forms
If your child is coming in for an immunization and a parent or legal guardian will not be present, please complete the appropriate form below giving our office permission to administer the appropriate vaccine(s).
– Injectable Flu Vaccine Administration Permission Form (must be completed same day of immunization).
– COVID Vaccine Administration Permission Form (must be completed same day of immunization).
– Typhoid Vaccine Advanced Beneficiary Notice (ABN)
Flu vaccine pick-up waiver
If your Allergist is requesting that you need to pick-up a flu vaccine from our office to be administered at the Allergist’s office, please complete and turn in this signed waiver form upon pick-up of the vaccine.
M-CHAT for 18 & 24 month check-ups
The M-CHAT questionnaire is a screening tool designed to identify children who should receive a more thorough assessment for possible early signs of autism spectrum disorder or developmental delay.
If you are registered, or would like to be registered, for the online tool CHADIS that allows you to complete questionnaires like this electronically from home, please click here.
However if you wish to print and complete the questionnaire, you can do so here. When you bring your child for their 18 month and 24 month check-up exam, please bring in the completed M-CHAT questionnaire with you to the visit and hand the completed form to the receptionist upon check-in.
Change of Insurance Form
If you have a change of insurance, please fill out this form. Please also submit a copy of your insurance card, both front and back, by sending us a message via your patient portal account.
Demographic Update Form
If you have an address change, please fill out this form and submit it to the appropriate office.
HIPAA Forms
If we do not have a signed HIPAA Policy on file, we will need one completed before we can release any information regarding a patient to anyone. Please fill out and submit the HIPAA form in its entirety.
Nutritionist – Food Record
If you have an appointment scheduled with our Nutritionist, prior to the appointment, please complete this 3 day food record and bring it with you to your appointment.
Disclaimer:
The tool to upload documents is not monitored by a Medical Professional. Please do not submit any requests that will require medical advice or triage.
