PATIENT INFORMATION

RESPONSIBLE PARTY INFORMATION

INSURANCE INFORMATION

PATIENT HISTORY

REFERRING PHYSICIAN INFORMATION

EMERGENCY CONTACT INFORMATION

I certify that the above information is true. By signing below I hereby authorize the release of information necessary to file a claim with my insurance
company and I assign benefits otherwise payable to me to the doctor indicated on the claim. I also understand that I am responsible for all denied
claims, co-pays, deductibles and co-insurance amounts as indicated by my insurance whether collected at time of service or not. I understand it is
ultimately my responsibility as the insured to understand the details of my insurance benefits.

I REQUEST AND AUTHORIZE THE FOLLOWING PHYSICIAN(S)/ FACILITIES TO RELEASE
INFORMATION FROM MY MEDICAL RECORD.

Patient Information

Who and Where to Send/ Release Information

Sant P. Chawla M.D.
2811 Wilshire Blvd # 414 Santa Monica, CA 90403
T: 310-552-9999 F: (310) 201-6685

Time Limit & Right to Revoke Authorization

Except to the extent that action has already been taken in reliance on this authorization, at any time I can revoke this
authorization by submitting a notice in writing to Dr. Sant P. Chawla at 2811 Wilshire Blvd Suite 414 Santa Monica, CA
90403. Unless revoked, this authorization will expire on the following date or event

or two years from the date of signature, unless otherwise specified.

Drug and/or Alcohol Abuse, and/or Psychiatric, and/or HIV/AIDS Records Release

* I understand if my medical records contain information in reference to drug and/or alcohol abuse, psychiatric care,
sexually transmitted disease, Hepatitis B or C, and/or other sensitive information I agree to its release:

  • I understand if my medical records contain information in reference to HIV/AIDS (Human Immunodeficiency.
  • Virus/Acquired Immunodeficiency Syndrome) testing and/or treatment I agree to its release:

Signature of Patient or Personal Representative Who May request Disclosure

I can inspect or copy the protected health information to be used or disclosed. I authorize the above listed
facilities/physician(s) to disclose the protected health information specified above.

For EACH of the above marked problems please list the following



Family History

Please list all Illnesses in Family (ie: stroke, cancer, diabetes etc…) and who currently has the illness.


Are you currently taking aspirin, Ibuprofen or other blood thinners? YES / NO If yes please list add to above list (s) above ↑.

I  certify the above medical history is true and correct to the best of my knowledge

Past surgeries and hospitalizations: (Use the reverse side if more space is required.)