Using our Online Pre-Admission Form
Please enter your information on the following pages. This form should take 10-15 minutes to complete.
You will need your insurance information. The fields with an asterisk are required and must be
completed in order for you to be able to submit the form. If these fields are left blank, your registration won't be sent.
California Pacific Medical Center assures protection of your personal health information. Our website securely
You can verify California Pacific Medical Center is collecting
your information over a secure site by clicking on the padlock icon
located near your browser's address bar to view our certification form.
California Pacific Medical Center is a not-for-profit organization. We recognize that medical bills are sometimes
unexpected and can be unaffordable. Because of this, California Pacific Medical Center has a financial assistance
program known as Charity Care. This program is designed to help patients who have no insurance, or limited insurance,
with their bills. Financial Assistance is based on income, assets and other factors. Confidentiality of information and
individual dignity will be maintained for all who seek this service.
For specific information on our financial assistance program, please call one of our Financial Counselors. If your last name begins with: A-G,
call (415) 600-6442; H-N, call (415) 600-6375; or O-Z,
call (415) 600-6395. You can also email inquiries regarding Charity Care to us at
Please be aware that we frequently approve Financial Assistance prior to providing services as well as after services are rendered.