Patient Forms

Dr. Bastidas request that you take the time to fill out these forms before arrival to the office.  We have found that it may be easier and less stressful to fill out these forms when you have reference to documents and/or medications you may forget to bring to the office the day of your appointment. Please bring the completed forms to the office the day of your appointment. If you cannot do so, please show up 15 minutes before your scheduled appointment time. Thank you in advance.  If you have any questions please do not hesitate to call the office.

 

If you are a Medicare patient you are excluded from completing the Out Of Network form as well as The Assignment of Benefit form.

 

If you use any other insurance/no insurance please complete all forms.

1. HIPAA Release Form
HIPAA Form--Bastidas (1).docx
Microsoft Word document [150.2 KB]
2. Patient Information
Patient Info-Bastidas (1).docx
Microsoft Word document [121.5 KB]
3. Medical Information Release
Release of medical info-Bastidas (1).doc[...]
Microsoft Word document [83.0 KB]
4. Assignments of Benefits
Assignment of Benefits-Bastidas (2).doc
Microsoft Word document [29.0 KB]
5. Out of Network Form
Thank you for choosing our practice (1).[...]
Microsoft Word document [181.3 KB]
6. Past Medical History
Please be aware that this is a 2 page document
Your Past Medical History (2).pdf
Adobe Acrobat document [155.0 KB]

National Surgical Associates

 

14981 National Ave. Ste 4

Los Gatos, CA 95031

  

Phone: (408) 358-4747

Fax: (408) 358-4742

 

 

Make an appointment by email

Our Business Hours

Mon-Fri :

09:00 am - 04:45 pm

Mon-Fri :

09:00 am - 04:45 pm

09:00 am - 04:45 pm

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