Get Ca Northridge Diagnostic Imaging Center Patient Information Form 2015-2026

Filling out the patient information form online is an essential step for receiving care at the CA Northridge Diagnostic Imaging Center. This guide provides easy-to-follow instructions to ensure that all required information is submitted accurately and efficiently.

Follow the steps to complete your patient information form online

1. Click ‘Get Form’ button to obtain the form and open it in your device.
2. Begin by entering your last name, first name, and middle name in the designated fields. Ensure all names are spelled correctly.
3. Input your Medical Record Number (MRN) and date of birth (DOB) in the respective fields, confirming the accuracy of the information.
4. Select your gender from the provided options.
5. Fill in your address, including two address lines if necessary, along with your city, state, and zip code.
6. Provide your home phone number, work phone number, and cell phone number. Make sure to indicate your preferred contact method.
7. Choose your preferred delivery method for correspondence, selecting mail or electronic options as appropriate.
8. Indicate your race and whether or not you identify as Hispanic, checking the relevant boxes.
9. Provide the name of the referring physician in the space provided.
10. For responsible party information, complete the fields with the last name, first name, relationship to the patient, and contact information.
11. In the primary insurance section, answer any questions regarding employment status, and fill out insurance details including policy number and group number.
12. Repeat the previous step for secondary insurance information if applicable.
13. Complete the medical information section, including questions regarding auto accidents or work-related injuries.
14. Provide your weight and height in the designated fields.
15. Fill out your smoking status and list any active medications, using the provided options.
16. Indicate any allergies you may have, including severity levels, checking all that apply.
17. For female patients, acknowledge pregnancy-related statements where applicable.
18. Sign and date the authorization and agreement section, confirming your understanding of the terms.
19. Review all entries for accuracy and completeness before submitting the form online. You can save changes, download, print, or share the completed form as needed.

Complete your patient information form online today and take the first step toward receiving your diagnostic imaging services.