Schedule a Housecall

We bring premium care to you

Register for a Housecall Appointment

Welcome. This practice is constructed around elders and their families. Our differences are explained below. In addition, we are required to have you acknowledge notification of several items. Please follow these 4 easy steps.

Step 1

Contact Us

  • This field is for validation purposes and should be left unchanged.

Step 2

fill out secure online enrollment form*

*Also available as download

IMPORTANT: The form does not ‘save’ and will ‘time out’ so please have all information at hand prior to submitting.

Step 3

fill out our 5 required forms

Once the appointment has been set up, there are 5 forms we need signed before we can begin working with your family. For your convenience you can securely sign up online and if you have any questions please call 650.357.8834 x1

Coverage Levels

This form indicates various coverage plans offered.

Services Agreement

This form details the various services we provide.

Notice of Privacy Practices

This notice describes our use of your medical information.

Authorization to Release Medical Information

This notice describes our use of your medical information.

Medicare Opt Out Contract

This notice confirms confirms you understand our Medicare Opt Out status.

Fees and Services

This form indicates various services offered with associated fee.

Step 4

COMPLETE PROCESS

 
After documents are faxed, call 650.357.8834 x1 to complete the registration process.