Forms & Documents

For Your Convenience

Forms & Documents

Advance Directive (PDF in English/Spanish)
Guild Volunteer Application
Dr. Marengo's New Patient Breast Health Questionnaire
Physician Orders for Life-Sustaining Treatment (POLST) (This will take you to the POLST site where you can download forms in multiple languages)

Occupational Health Forms

Treatment Authorization
Drug Screen & Physical Authorization
Consent for Drug Screen of a Minor
Flu Vaccination Voucher

Financial Counseling

Financial Assistance Program Policy
Financial Assistance Program Plain Language Summary
Financial Assistance Application Form
Uninsured Discount Program

Primary Care

Consent for Treatment & Financial Agreement
- English
- Spanish
Treatment & Financial Agreement Acknowledgment
- English
- Spanish
Medical History Form
- English
- Spanish
No Show/Late Arrival Form

Insurance	Medical Group	Hospitals	Surgery
Aetna HMO **
Aetna: PPO, EPO, POS
Anthem Blue Cross HMO (specialty referral only) **
Anthem Blue Cross PPO, EPO, POS, PPO/EPO
Anthem MediBlue Access (PPO) Medicare Advantage
Anthem MediBlue Dual Access (PPO D-SNP)(Medicare/Medi-Cal)
Anthem Medical Local Preferred Provider Organization (LPPO). (Out-of-state Blue Cross/Blue Shield Medicare Advantage PPO)
Anthem Medicare Preferred PPO Plan
Blue Cross Blue Shield PPO
Blue Shield HMO: Access+, Individual Family Plan, Local Access+, Providence Option Plus, SaveNet **
Blue Shield, Standard PPO, POS
Brand New Day Medicare Advantage Plan (specialty referral only)
*New* CalPERS: Anthem Blue Cross Traditional HMO **
CalPERS: PERS Platinum (PPO) and PERS Gold (PPO)
CHAMPVA
Cigna HMO, PPO, POS
Compass Rose Plan
*New* Covered California: Anthem Blue Cross PPO
*New* Covered California: Blue Shield HMO **
*New* Covered California: Blue Shield PPO
Covered California: Western Health Advantage
FEHB: Blue Cross Blue Shield PPO
First Health/Coventry PPO, EP
GEHA PPO Plans
Health Net HMO: Blue & Gold, SmartCare - CalPERS, WholeCare **
Health Net PPO, POS
Health Smart EPO
Health Smart POS
Health Smart PPO
Mail Handlers Benefit Trust PPO, POS
Medi-Cal
Medicare
Medicare Supplemental Plans A-N (i.e. AARP, Mutual of Omaha, etc)
MultiPlan/Private Healthcare Systems (PHCS) PPO, POS
Partnership HealthPlan of CA (Currently not accepting new patients for Primary Care)
Private Healthcare Systems PPO, POS
Three Rivers Provider Network PPO
TRICARE (includes TRICARE for Life)
UnitedHealthcare AARP Medicare Advantage Choice (PPO)
UnitedHealthcare Employer Retiree Medicare Advantage Plan PPO
UnitedHealthcare HMO: Signature Value, Signature Value Focus **
UnitedHealthcare Medicare Advantage Assure (HMO)
UnitedHealthcare PPO, EPO, POS
UnitedHealthcare, AARP MedicareComplete, SecureHorizons (HMO)
Western Health Advantage
Western Health Advantage MyCare & MyCare Plus