Your physician has referred you for Outpatient Services at California Pacific Medical Center.
This online form will allow you to complete the pre-registration process at your convenience
from your home or office. Please enter your information on the following pages.
The form should take about 15 minutes to complete. Be sure to have your insurance information handy.
The fields with an asterisk are required and must be completed in order for you to submit the form.
If any of these fields are left blank, we will not be able to process your registration.
In order to serve you better, we ask that you provide us with a preferred day and time for us to contact you.
You will have an opportunity to provide this information in the "Comments" section on Page 5.
When we receive your completed form, one of our registration staff will contact you as requested to schedule
your initial appointment. (Note: This pre-registration process applies only to this outpatient visit.)
California Pacific Medical Center assures protection of your personal health information.
Our website securely transfers your information to our data systems.
You can verify California Pacific Medical Center is collecting your information over a
secure site by clicking on the lock image
at the bottom of this browser window to view our certification form.
California Pacific Medical Center is a not-for-profit organization,
and we recognize that medical bills are sometimes unexpected, and can be unaffordable.
Because of this, California Pacific Medical Center has a
financial assistance program also known as Charity Care.
This program is designed to help patients that 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 that seek this service.
For specific information on our financial assistance program, please call and speak with one of our
Financial Assistance Analysts at (415) 600-7113 or (415) 600-7204.