1. New Patient Registration Forms.pdf
If you are a new patient, please click New Patient Registration Forms, fill them out, save it in your computer, and then upload it in the Contact.
Second option is to e-mail it to firstname.lastname@example.org.
Third option is to fax it to 310.372.9358.
Fourth option is to bring it to your appointment.
*Make sure you include the complete list of your current medications and your preferred pharmacy's name and phone number, or
mail order's name and address.
2. Bring your health insurance card and a driver's license or ID
Make sure that Dr. Cha is an In-Network provider of your insurance (See Insurance and Policies).
3. If you are under 18 years old, you must be accompanied by a parent(s) or a legal guardian.
4. Co-pays, deductibles and all cash visit payments are required at the time of your visit.
5. If you want us to speak with other person(s) regarding your protected health information,
fill out the following form and upload, e-mail, fax, or bring it to us: Authorization for Confidential Communications.pdf
6. If you would like our team to coordinate care with another physician practice,
please complete the form below to authorize the release of your medical records from us, or
the authorization for another physician practice to disclose information to us:
Medical Record Release Request Form-- Release FROM Dr. Cha.pdf
Medical Record Release Request Form-- Release TO Dr. Cha.pdf
7. If you want to have a copy of Notice of Health Information Practices by HIPAA (Health Insurance Portability and Accountability Act):
Notice of Health Information Practices (HIPPA).pdf
8. If you want to make a payment with credit card, call us with your credit card information,
or fill out the following form and upload, e-mail, fax or mail it to us:
Credit Card Payment Form.pdf