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Forms & Documents

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Forms & Documents

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Patients & Visitors

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For Your Convenience

Forms & Documents  

  • Advance Directive (PDF in English/Spanish)
  • Guild Volunteer Application
  • Patient and Family Advisory Council 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 Application Form

Making an appointment is easy

Care 'til 8 — Care when you need it.
Center for Primary Care
Fairfield(707) 646-5500
Green Valley(707) 646-5500
Vacaville(707) 646-5500
Center for Women's Health
Fairfield(707) 646-4100
NorthBay Urgent Care
Vacaville(707) 624-7400
Specialty Practices
Fairfield(707) 646-4180
Vacaville(707) 624-7999
Cancer Center
(707) 646-4000
Cardiac & Pulmonary Rehabilitation
(707) 646-5072
Center for Women's Health
Fairfield(707) 646-4100
Diabetes & Endocrinology
(707) 624-7999
Gastroenterology
(707) 646-3555
Orthopedics
Vacaville(707) 624-7900
Fairfield(707) 646-5599
Solano Diagnostic Imaging
Vacaville(707) 624-7575
Fairfield(707) 646-4646

Returns

When To Call 911

A medical emergency is an event that you reasonably believe threatens your or someone else's life or limb in such a manner that immediate medical care is needed to prevent death or serious impairment of health. A medical emergency includes severe pain, bad injury, a serious illness, or a medical condition that is quickly getting much worse.

Is the condition life or limb threatening?

Could the condition worsen quickly on the way to the hospital?

If you move the victim, will it cause further injury?

Does the person need skills or equipment that paramedics or EMT's carry right away?

Would distance or traffic cause a delay in getting the person to the hospital?

If the answer is yes to any of these�.call 9-1-1.

Let's find your perfect doctor!

Choosing NorthBay is as easy as selecting any of the plans below!

Insurance Medical Group
(Outpatient physicians)
NorthBay Centers for Primary Care
NorthBay Medical Group
Hospitals
NorthBay Medical Center
NorthBay VacaValley Hospital
Aetna PPO, EPO, POS
Aetna HMO
Anthem Blue Cross PPO, EPO, POS, PPO/EPO
Anthem Blue Cross HMO
CalPERS: PERSCare (PPO), PERS Choice (PPO), PERS Select (PPO)
CHAMPVA
Cigna PPO, HMO
Cigna POS
Compass Rose Plan
Covered California - Western Health Advantage
First Health/Coventry PPO, EPO
GEHA PPO Plans
Health Net PPO, POS, HMO
Health Smart PPO, POS
Mail Handler's 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
TRICARE (includes TRICARE for Life)
United Healthcare PPO, EPO, POS
United Healthcare HMO
United Healthcare Employer Retiree Medicare Advantage Plan PPO
United Healthcare, Secure Horizons, Medicare Advantage, HMO 2019
Western Health Advantage
*Blue Shield* For Blue Cross/Blue Shield /Blue Card Program, plans vary, please call Managed Care Department to see if yours is in network, (707) 646-3289.

If your plan is not listed, please feel free to check directly with our health plan specialist, Kelly Rhoads-Poston at (707) 646-3280 or KRhoadsPoston@NorthBay.org or your health plan administrator to see if NorthBay Healthcare is included in your plan's network.

About NorthBay

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Future Employees

  • NorthBay Careers
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Community Resources

  • Event Calendar
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  • Annual Nurse Camp
  • Health Education Seminars
  • Support Groups
  • Meet Our Bloggers
  • Wellspring Magazine
  • For the Media

Patients & Visitors

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NorthBay Notices

  • Community Health Needs Assessment
  • Community Benefits Plan
  • Annual Report
  • Annual Nursing Report
  • Utilization Management Information

For Staff

  • Employee Portal
  • Medical Staff Services


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