FORMS.

a little bit of time now, will save you a lot later

Please download, print, and complete ALL forms provided in the link.

If you have any questions on the Patient Intake Form, please call the office at 805-612-5293. 

For billing and insurance questions, email Victoria House at vhouse@housebilling.com   

Please remember to bring your completed forms, along with the following pieces of information, to your scheduled appointment:

  • Insurance card

  • Photo ID

  • Referrals (If required by your insurance)

  • Co-payments (If required by your insurance)

Please use the link provided to download and print the patient forms. 

 

  • If you are using insurance, please click on the button below and complete the Insurance Form:

  • If you are paying privately, please click on the button below and complete the Private Pay Form:

 

 

 

 

Send the Patient Information & Financial Agreement Form

to the billing office at: VHOUSE@HOUSEBILLING.COM 

- OR-

Fax to (866) 849-0672.

*YOUR INFORMATION WILL BE VERIFIED AND CONFIRMED VIA EMAIL*

 

Financial Policy ​

We require prior verification of eligibility in order to use insurance as the method of payment. If insurance has not been verified, the appointment will be charged out-of-pocket and the fee will be collected at check-in. 

 

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