Forms

All forms are in PDF format, viewed with Adobe Acrobat Reader (free download)

Kaiser, ASH

For patients referred from Kaiser or with acupuncture benefits managed by American Specialty Health (ASH), please download the following forms for your first visit:
New Patient Registration
Office Policies
ASH Initial Evaluation

All other PPOs, HMOs

For patients with any other insurance or if acupuncture is not covered by your insurance, please download the following forms for your first visit:
New Patient Registration
Office Policies

Workers comp

For patients being referred through workers comp, please download the following forms for your first visit:
New Patient Registration
Office Policies
General Pain Index Questionnaire

In addition, please download the appropriate pain evaluation form/s relating to the area of the injury on your claim:
Neck and upper back
Shoulders and arms
Low back and pelvis
Hips and legs

Miscellaneous

DWC Mileage Log
DWC Injured Workers Guide
DWC Una Guia para Trabajadores
Medical Records Release Form

5839 Green Valley Circle, Ste 201
Culver City, CA 90230
Tel: 424-543-6775
Fax: 424-543-6776