Información del Paciente

Información del Paciente
Nombre*
Nombre Apellido
Dirección
Numero / Calle / Apto # Ciudad Estado Zona Postal
Teléfono de Casa
Teléfono Cellular
Email
Sexo
Casado
Fecha de Nacimiento*
MM slash DD slash YYYY
Número Social
Licencia de Manejar #
Queja
Relacionado con trabajo?*
Nombre del Trabajo
Teléfono
Dirección del Trabajo
Numero / Calle / Apto # Ciudad Estado Zona Postal
Puesto
Información de Cónyuge/Padres
Nombre
Nombre Apellido
Dirección
Numero / Calle / Apto # Ciudad Estado Zona Postal
Teléfono
Número Social
Licencia de Manejar #
Es una lesión relacionada con el trabajo?*
- Sí
- No
Información de Seguro
Nombre del Asegurado/Garantisador
Nombre Apellido
Relación con el Paciente
Nombre del Seguro de Compania
Dirección
Numero / Calle / Apto # Ciudad Estado Zona Postal
Numero de ID
Numero de Grupo/Nombre
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1. MEDICAL CONSENT: The undersigned consent authorizes any medical treatment, examination, laboratory procedure, x-ray examination, or physical therapy treatment that may be considered advisable or necessary for the patient in the judgment of the attending physicians.
2. FINANCIAL AGREEMENT: The undersigned agrees, whether signing as a patient or as an agent, that in consideration of the services to be rendered to the patient, the undersigned shall have the obligation to pay the account of the patient with Healthline Medical Group in accordance with the regular rates and terms of Healthline Medical Group as in effect. Such account shall be due and payable at the time of discharge unless other arrangements are approved in writing prior to such time by Healthline Medical Group, which shall have sole discretion whether to approve other payment arrangements. If the patient’s account is not paid when due, it shall bear interest from the due date at the maximum for the account of the patient on any deferred basis, and payment is not made when due. Healthline Medical Group shall have the immediate right to charge such sum to the credit cards of the undersigned listed hereon. the undersigned’s signature(s) herein constituting complete authorization to Healthline Medical Group to charge such credit cards. If the patient’s account is referred to a collection agency and/or an attorney for collection, the undersigned shall pay all attorneys’ fees for costs of collection.
3. MEDICARE: Patient’s Certiﬁcation, Authorization to Release information, and Payment Request: The undersigned certiﬁes that the information given in applying for payment under the Title XVIII of the Social Security Act is correct. The undersigned authorizes any holder of medical or other information about the patient to release to the Social Security Administration or its intermediaries or carriers any information needed for this or any related Medicare claim. The undersigned requests that payment of authorized beneﬁts he made on the patient’s behalf.
4. RELEASE OF INFORMATION: Healthline Medical Group may disclose all or any part of the patient’s record to any person or corporation which is or may be liable under a contract to Healthline Medical Group or to the patient or to a family member or employer of the patient for all or part of Healthline Medical Group charges, including, but not limited to, hospital or medical service companies, workmen’s compensation carriers, welfare funds, or the patient’s employer. All such information would be available after a written request and the approval of the attending physician.
5. RELEASE OF MEDlCAL RECORDS: The undersigned authorizes the release of information in the patient’s medical records to his/her private physician and to any physician, hospital, or agency to which Healthline Medical Group refers the patient. The undersigned also authorizes any physician, hospital, or agency to which the patient is referred the release of information to Healthline Medical Group regarding treatment by said physician, hospital, or agency.
6. DISCLOSURE: The x-ray and physical therapy departments are owned and operated by Healthline Medical Group. Healthline Medical Group bills for services provided by the Orthopedist and other Specialists performing services in this clinic inclusive of the EMG nerve conduction studies.
7. INSURANCE ASSIGNMENT: The undersigned hereby authorizes payment directly to Healthline Medical Group of any beneﬁts payable to the patient including disability insurance and payment under Title XVIII of the Social Security Act, which is applicable to the patient’s account. The undersigned understands that he/she is ﬁnancially responsible to Healthline Medical Group for the charges not covered by the patient’s insurance plan.
8. RELEASE FOR FUTURE CONTACT: The undersigned hereby authorizes Healthline Medical Group’s staff to contact the patient for information relating to the patient’s medical condition.
The undersigned certiﬁes that he/she has read the foregoing and is the patient, or duly authorized by the patient as patient’s general agent to execute the above and hereby accepts its terms.*
- I Agree
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Patient Reviews

Healthline Medical Group is a trusted medical care provider that has earned numerous positive reviews from our patients. You will experience the same advanced and compassionate care that has made us the go-to healthcare provider serving the San Fernando Valley. Schedule an appointment today.

“Incredibly refreshing to go to a medical facility today where the entire staff is seemingly happy to be there. All of the employees at Healthline Medical were so friendly, helpful and professional. Having worked in the medical profession for 12 years- I’m a tough critic. I can honestly say Healthline Medical Group exceeded my expectations - I highly recommended without reservation.”

Claudette M.

“I have always received excellent care and follow up from Healthline Urgent Care. The staff is very caring and professional. They really know their stuff. They also do an outstanding job of getting patients in and out in a timely fashion. I highly recommend!”

Gary J.

“Very friendly and very thorough, showed great concern for the medical issues you are feeling. Took down all my information and medical history, asking the right questions. I felt very comfortable with the staff and the medical doctor, she was very kind and knowledgeable. It definitely made going to urgent care a pleasant experience when usually it isn’t.”

Shelle I.

Información del Paciente

Información del Paciente

Información de Cónyuge/Padres

Información de Seguro

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Meet Our Team

Emmett A. Berg, D.O.

Barry S. Rosenblum, D.O.

Gary I. Reyzin, M.D.

Chrystelle Williams, MPAS, PA-C

Tim Jones, MPAS, PA-C

Sarah Jadin, MPAS, MS, PA-C, RD

Emily Christel, PA-C

Sarah Ahdout, PA-C

Hrair E. Darakjian, MD

Patient Reviews

Healthline Medical Group

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