• Demographic Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Language*
  • Ethnicity*
  • Race*
  • Preferred Contact Method*
  • Why are you needing services from us?*

  • In case of emergency

  • Format: (000) 000-0000.

  • Insurance Information

  • We're Sorry – Insurance Not Accepted
    Unfortunately, we are not accepting new patients with your current insurance provider. As a result, we’re unable to proceed with the form at this time.

  • Insurance card- Primary (Please either take a picture or upload picture of your Insurance card)*
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  • Insurance card- Secondary (if applicable)
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  • Drivers License
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  • Patient Financial & Payment Policy

  • This financial payment policy is an agreement between Stark Medical and you, the patient, or the responsible party. By signing the patient registration form, you are acknowledging that you understand and agree to our financial payment policy.

    Patient Responsibility:

    • You must provide us with a current insurance card and billing information. Your insurance policy is a contract between you and the insurance company. It is your responsibility to know your insurance benefits and pay any remaining portion due afterinsurance processes your claim.
    • Co-pays are due at the time of service.
    • NSF Fees: A $20.00 returned check fee will be charged for checks returned due to insufficient funds.
    • No-Show Fee: If you do not cancel or reschedule your appointment with at least 24 hours notice, we may asses a $50 "No-Show" service charge to your account. This "no-show charge" is not reimbursable by your insurance company. You will be billed directly for it. If you have 2 or more no-shows, we MAY discharge from practice. 
    • Effective 1/1/2024 Stark Medical will be implementing a service charge for completion of forms that are not completed within a scheduled office visit. Examples include: Physical forms, Disability forms, FMLA, Driver's License forms, Handicap Placard, and Prior Authorization Requests.

    I understand that I am financially responsible for all charges regardless of third-party involvement. I agree to pay any deductible, co-insurance; copay, or any service(s) deemed a “non-covered benefit” by my insurance company. 

    Under California law (Civil Code Section 1785.27), medical debt holders are prohibited from reporting unpaid medical debts to consumer credit reporting agencies. This means that any unpaid balance for services received at our practice will not appear on your credit report. However, please note that unpaid debts may still be pursued through other legal avenues, including direct communication and collection efforts by agencies working on our behalf.

    Additionally, if a debt holder knowingly violates this law by reporting medical debt to credit agencies, the debt will become void and unenforceable under California law. While this protects patients from credit reporting impacts, it does not eliminate the obligation to pay for services provided.

    To ensure the sustainability of our practice and to continue providing high-quality care to all patients, we kindly request that all outstanding balances be paid promptly. If you are experiencing financial difficulties, we encourage you to contact us as soon as possible to discuss payment options or financial assistance programs that may be available to you.

    Please also note that patients who fail to meet their financial obligations may be subject to discharge from our practice, as we must take steps to prevent further uncollectible debt from being incurred. We hope this will not be necessary and are committed to working with you to resolve any outstanding balances in a fair and respectful manner.

    Consent for Communication Regarding Payments

    I understand and agree that Stark Medical may contact me via text message and/or voice call using the phone number(s) I have provided. These communications may include information related to billing, account balances, and payment reminders. I acknowledge that standard message and data rates may apply, and I may opt out of these communications at any time by notifying the office in writing or following the opt-out instructions provided in the messages.

    By signing below, I give my consent to receive such communications for the purpose of payment collection and related account management.

  • Credit Card on File

  • Stark Medical offers a Credit Card on File program as a convenient method of paying for the portion of your services that are patient responsibility such as copay, deductible, and co-insurance. Your credit card information will be kept confidential
    and secure.

  • Credit Card on File Authorization*

  • I, the undersigned, authorize and request that Stark Medical charge my credit card for the balance due that my health plan has identified as my financial responsibility. This authorization relates to all charges not covered by my insurance company for services provided to me by Stark Medical. My card will remain securely stored for future use by Open Edge, a secure credit card processor affiliated with Global Payments Merchant’s Services that partners with Stark Medical to collect payments. This authorization will remain in effect until revoked by me in writing.

  • Once your new patient packet has been accepted, you will receive a secure text message from HealowSign requesting your credit card information. This is part of our process to keep your card on file for future visits.

    Please feel free to reach out if you have any questions.

  • Health History

  • Personal History- Please check all that apply
  • Are you currently under the care/ being treated by any Specialist? (Cardiologist, Urologist, Endocrinologist, Dermatologist, etc)*

  • Provider/Facility Name: Specialty: Contact #:      
    Provider/ Facility Name: Specialty:  Contact #:   
    Provider/ Facility Name: Specialty:  Contact#:     
    Provider/ Facility Name: Specialty:  Contact#:   
    Provider/ Facility Name: Specialty:  Contact#:     

  • Family History
  • Taking any medications, currently?
  • Do you have any Allergies?

  • Smoker:     If yes, How many cigarettes a day?
    Alcohol Consumption:      If yes, how many drinks per day?      
    Caffeine Consumption:      If yes, how many caffeinated beverages per day?         
    Recreational drugs:     Please list any street drugs you formerly or currently use:      
       

  • Personal Health Information

  • Please check all that apply and list name(s) below:

  • Name: Relationship: Contact #:      
    Name: Relationship:  Contact #:   
    Name: Relationship:  Contact#:      

  • Upon request, I may limit the amount of time that this consent for release of information is valid. I may revoke this authorization, in writing, at any time. I understand that the revocation will not apply to information that has already been released. I understand that authorizing the disclosure of this information is voluntary.

  • Patient medication history is a list of prescriptions that healthcare providers have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history.
    The collected information is stored in the practice electronic medical record system and becomes part of your personal medical record. Medication history is very important in helping providers treat your symptoms and/or illness properly and avoid potentially dangerous drug interactions.
    It is very important that you and your provider discuss all your medications in order to ensure that your recorded medication history is 100% accurate. Some pharmacies do not make prescription history information available, and your medication history might not include drugs purchased without using your health insurance.
    Also over‐the‐counter drugs, supplements, or herbal remedies that you take on your own may not be included.
    I give my permission to allow my healthcare provider to obtain my medication history from my pharmacy, my health plans, and my other healthcare providers.

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