Forms

To make sure you have what you need when you need it, we've put some of our most requested forms online.

Important Note: There are different forms for request of medical records.

• Salinas Valley Health Clinics: Click Here

• Salinas Valley Health Medical Center: the form directly below this notice

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RELEASE OF MEDICAL INFORMATION FOR Salinas Valley Health Medical Center

Authorization for Use or Disclosure of Medical Information Form

1. Print the authorization form.
2. Fill in all the information. Sign and date the form.
3. Make a readable copy of Driver's License.
4. You may fax, mail or e-mail your authorization form and the copy of the Driver's License to:
   1. Fax: 831-753-6295
   2. E-mail: himlegal@SalinasValleyHealth.com
   3. Mail: HIM Department, 450 East Romie Lane, Salinas, CA 93901

DIVULGACIÓN DE INFORMACIÓN MÉDICA POR Salinas Valley Health Medical Center

Formulario de divulgación y uso de información médica

1. Imprima el formulario de autorización.
2. Complete el formulario. Firme y ponga fecha.
3. Haga copa legible de su licencia de conducir.
4. Puede enviar por fax, correo, o email su autorización y una copia de su licencia de conducir.
   1. Fax: 831-753-6295
   2. E-mail: himlegal@SalinasValleyHealth.com
   3. Correo: HIM Department, 450 Romie Lane, Salinas, CA 93901

ADVANCED DIRECTIVES/ADVANCE CARE PLANNING

Specially trained volunteers are available to assist you and your family with Advance Directives. Call 755-0772 to schedule an appointment. Learn more.

MEDICATION AND ALLERGIES LIST

There are two vital questions your doctor must ask before treating you. Do you have any allergies and are you taking medications? It takes hardly any time at all to complete the forms that list allergies and medications but this bit of organization might ensure your health and safety at the most critical time. Once completed, keep an updated copy of the forms in your wallet/purse so it will be available at all times. Download a Medication Safety brochure

Download a Medication List to fill out and bring with you.

SALINAS VALLEY HEALTH CLINICS FORMS

Planning a visit to Salinas Valley Health Clinics? Save yourself some time by filling out the relevant forms listed below. Hand this in to the front desk once you arrive. If you have questions, a member of our staff will be happy to assist you.

PrimeCare

• Consent to Treat a Minor – We require a guardian’s expressly written permission to treat minors.
• Record Release Form – Having your medical records transferred from another healthcare provider can be important to your treatment. Fill out and bring this form if you need to transfer your medical history.
• New Patient Registration Form – Please fill this out if you have never visited our clinic before. If you cannot fill it out at home, you can ask the front desk for once when you arrive.
  • Spanish New Patient Registration Form

Sleep/Wake

• New Patient Registration Form – Please fill this out if you have never visited our clinic before. If you cannot fill it out at home, you can ask the front desk for once when you arrive.
  • Spanish New Patient Registration Form

Referral Process

If you have been referred to a medical specialist or laboratory outside of Salinas Valley Health Clinics you may need authorization from your insurance company. Appointments are scheduled by our check-out personnel. Filling out the paperwork may take a few days, after which you will be contacted with appointment details.

If you do not know whether or not you require authorization from the insurance company, the doctor will fill out an authorization request form and send it to our authorization department. This department interacts with the insurance companies to learn more about their process. Hammering out all the details can take a few days or more than a week. If it is an emergency situation, the requests will be labeled “URGENT” and processed immediately.