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Please note:

Dr. Jorgensen has had a name change to Dr. Nanos. As we complete changes in our system and with insurances, her patients will hear and see this new name replace the other. Thanks!


   Forms

Dear Patient,

Thank you for choosing the North Coast Family Medical Group to provide your healthcare needs. Below are the necessary forms that you will need to complete for your visit. By completing the forms prior to your visit, we will be able to limit your waiting time and better review your medical history. You have the choice of either mailing all of the forms to us in one envelope or bringing all of the completed forms with you to your visit. If mailing, please allow 3-4 days for delivery and we encourage you to call to confirm they have been received.

  • New Patient Forms
  • Medical Records
  • Miscellaneous Forms

  • Adobe Acrobat is required to print these forms. To get acrobat, click here.


    New Patient Forms

    **Please note that forms 1, 2(or 3), 4 and 6 are required for visit so you should have at least four forms in hand for visit along with your insurance card and photo ID**

    1. Registration/HIPAA Form
    All lines must be completed and the form signed and dated.

    2. Adult/Adolescent History Form
    Please provide as much history as possible by filling out both pages fully.

    3. Child History Form
    For patients under age 15, please provide as much history as possible by filling out both pages fully.

    4. Medical Records Release Form

    We need your previous physician to release copies of your medical chart to us so we can have access to your complete medical history. Complete the highlighted portions and bring or send the form directly to that physician or medical group. If you have multiple physicians, you will want to make copies of the form and send one to each of your physicians.

    5. HIPAA Privacy Policies
    The Health Information Portability and Accountability Act requires us to make this information available to you. You may print this and keep it for your records or view for your information. Our registration form states that you have received a copy, so we can provide one at the office also if you wish.

    6. NCFMG Billing Policy
    We ask that you become familiar with our Billing Policies and sign this form to indicate your awareness.


    Medical Records Forms

    1. Have Your Records Sent to Us
    Use this form if you have records at a previous physician’s office and would like to have them transferred to our office.

    2. Send Your Medical Records Elsewhere
    A CD copy of our record of your care is available for a fee of $25 plus postage provided the record does not exceed 700MB.  If you need records transferred to another physician’s office, we will send the CD copy at no charge as a professional courtesy to that office.  If you prefer a paper copy, the copy fees including postage are as follows:
      • Less than 20 pages = $25.00
      • 21-50 pages = $30.00
      • 51-70 pages = $35.00
      • 71 pages or over = $35.00
        plus .10 cents for each page over 70


    Miscellaneous Forms

    1. State Disability
    Use this link to go to the Employment Development Department (EDD) home page to look for disability forms and other related information.

    2. Application for Disabled Person Placard or Plates
    Use this link to go to the California Department of Motor Vehicles website to apply for a handicapped placard or license plates.

    3. Consent to Treat a Minor

    4. Interval History


    If you have any questions regarding these forms
    please call us at (760) 942-0118.
    We look forward to seeing you!


    Copyright 2010. North Coast Family Medical Group. Last updated June 2015