+ New patients

We are attempting to schedule New Patients as our schedule allows, we are unable to provide a timeline or estimate for a new appointment.

Completing this form does not guarantee a New Patient Appointment.

We do not accept Medi-cal or Partnership.

Please download THIS FORM. Once completed please fax or email the document to our office at:

Fax: 530-244-7246 or Email: staff@californiafamilymed.com

Patients not seen in the last 3 years must reestablish with the practice.

+ LATE AND MISSED APPOINTMENTS

Please call us if you are running late, if a patient arrives over 7 minutes late to a appointment they may be asked to reschedule. Late arrivals do not give our provider appropriate time for a full assessment therefore we reschedule

• A missed appointment for a new or initial appointment will not be rescheduled

•A $50 fee for each missed follow up appointment and a $100 fee for a missed Wellness, Physical or Procedure appointment will be applied to your account. This will need to be paid prior to your next appointment.

•Failure to show to three (3) consecutive appointments will results in dismissal from the practice.

We understand that appointments sometimes need to be changed, we ask that you please call 24 hours in advance if you can not make your appointment.

+ RECORDS REQUESTS

Patients requesting to transfer records from another Doctor's office, hospitals and health care facilities must complete a Records Request Form and submit it to our office in order to allow us to obtain said records:

Authorization for Medical Records Request

+ MEDICATION REFILLS

We are responsible for refilling medications within 72 hours from the time requests are made.

Certain medications are unable to be written or refilled electronically or over the phone, in this case written prescriptions must be hand carried to the pharmacy.

As of February 2018, FDA guidelines require random screenings in order to write and refill certain controlled substances. The frequency and regularity of these screenings it at the discretion of this office.

The frequency and regularity of appointments for any medication is at the discretion of this office and may be dependent on adherence and patient status.

+ AUTHORIZATION TO TREAT MINORS

In order to treat patients under the age of 18 a parent of guardian must fill out and submit the form below:

Authorization to Treat Minors.pdf

+ DMV PHYSICALS

Please complete and submit the form below to our office prior to scheduling your appointment for DMV physicals.

There is a non-refundable $25.00 deposit for DMV physicals, due at the time of scheduling, and a $125.00 fee for the physical. These physicals are not billed through medical insurance due to being an "administrative" physical.

DMV Physical Form.pdf

+ DISABILITY AND FAMILY MEDICAL LEAVE

• GENERAL DISABILITY INFORMATION In order to initiate disability please complete the patient questions on the EDD site. edd.ca.gov Please know that it is your responsibility to file and or manage your claim, after you have submitted your claim contact the office. We will submit the medical portion of your claim by the end of the week. Please understand this may mean Friday afternoon.If your paperwork or claim has not been completed by the following Monday please contact the office. In order to extend disability dates an appointment is necessary to support the need for extension. Please make sure to schedule this prior to the end date of your disability. At your appointment it is necessary to establish a date of return - EDD does not accept open ended dates. It is also important to notify the front staff of the extension in order to have extension paperwork completed in a timely manner. Please at your appointment pay the EDD extension as well as notify the staff of the extension at your appointment.

• PREGNANCY/ FAMILY MEDICAL LEAVE Pregnancy disability allows for 6 weeks off (after vaginal delivery) or 8 weeks off (after c-section). Pregnancy disability allows a patient to take time off before she delivers (starting at 36 0/7 weeks). Pregnancy disability may apply prior to 36 0/7 weeks only if a patient has a serious complication (such as preterm labor or pre-eclampsia requiring bed rest). It cannot be used for general pregnancy complaints. The state will mail you a form to complete after your due date, in order to extend your disability. To cover additional employee time costs, our office charges a one-time, nonrefundable fee of $20 for application processing. The state processes applications faster online than on-paper. For paper applications: obtain papers from your employer, state disability office, or private disability company. For online applications: Go to www.edd.ca.gov/disability/ and click on register for a new online account. In blue click on continue to claimant registration and complete and submit. The website will give you a 15 digit number starting with the letter “R”. Provide our office with: 1) date of last day worked 2) $20.00 fee 3) the signed and completed paperwork or the “R” number For any questions call 1-877-652-0731, or logon to the disability website www.edd.ca.gov/disability/ or visit the local office at 1325 Pine St. Redding, CA 96001.

• SUPPLEMENTAL DISABILITY Matrix requires a letter from your provider stating the dates you are unavailable for work as well as forms completed at the time of the initial claim for disability. Please make sure your provider presents you with a note to give to the front staff to send at the time of the visit. Not all our patients use Matrix and therefore it is the patient’s responsibility to notify the front office staff. This will allow for a quick response to Matrix. Although we do not receive confirma- tion from Matrix, they do send paperwork. If Matrix contacts the patient and states we have not completed the initial paperwork please have the paperwork resent to the office, chances are we have not received the paperwork. Fax: 530-244-7246 If Matrix states they have not received an extension please contact the office in order for a staff member to resend the extension. All Matrix forms will be completed by the end of the week. Please understand this might be Fri- day afternoon. If your paperwork or claim has not been completed by the following Monday please contact the office.

+ ONLINE RECORDS

Gain access to your medical records by requesting a Patient Portal Invite. Call our office for an invitation to view your labs, imaging and chart notes.

+ PRACTICE FUSION PATIENT PORTAL

Click HERE in order to learn how to sign up and access your medical records via Practice Fusion, our electronic health records system