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
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 our Financial Counselor Supervisor at
(415) 641-6463 or e-mail firstname.lastname@example.org for an information packet and application.
Please be aware that financial assistance eligibility is often determined after services are rendered, and the hospital deposit requirements have been met.
To inquire about the status of your application, please call our Customer Service at (415) 600-7289.