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New Patient Paperwork

Thank you for choosing Miki and Alfonso Hand and Upper Extremity Center. We look forward to your visit.

If you would like to complete the new patient paperwork prior to your visit, please print the required forms and bring them completed to your appointment. If you would prefer to complete the new patient paperwork at the time of your appointment, our front desk staff can provide these forms to you at the time of your check-in.

Thank you.

 

Step 1: Please complete the New Patient Intake Form (English and Spanish).  

Step 2: Please complete the Continuity of Care Form (English or Spanish)

Step 3: Please complete the form that applies to your situation.

     Situation 1: I will be using my health insurance (English or Spanish)

     Situation 2: I was involved in an accident and will be using a Personal Injury Protection (PIP) Policy (English or Spanish) and my health insurance as secondary. (Note: Three more forms required on check-in.)

     Situation 3: I will be using my employers' Workers Compensation Policy (English or Spanish). (Note: Your case manager and/or adjuster must be aware of your appointment.)

     Situation 4: I have an attorney and will be being seen under an Letter of Protection which my attorney has arranged.

     Situation 5: I will be paying for myself (English or Spanish). 

Step 4: Bring your completed paperwork to your appointment.