Forms

Below are the forms necessary for registration. To save you time, please complete all forms and have them ready with you for your visit. If you would like to schedule an appointment please call us at 408-246-9926 or schedule via our online office. Returning Patients we have not seen in the last 6 months must fill out a new Patient Registration form and Office Financial Policy form.

*If you use our online office (Relay Health) you will still need to complete the forms below.

Form Description Formats
1 Registration form Patient and Insurance info pdf
2 Office Financial Policy Payment Requirements and Fees online | pdf | word
3 Confidential Communication Preference Communication Preference Form pdf
4 HIPAA Acknowledgement Acknowledgement of notice pdf
5 Physician-Patient
Arbitration Agreement
pdf
6 HIPAA Information packet Notice of privacy practices online | pdf | word
7 Medical Record Release form Authorization for Dr Washington to release medical records to another doctor (not required) pdf
8 Medical Record Release form Authorization Requesting medical records release from another doctor to Dr Washington (not required) pdf