Listed here are forms available online for Palo Alto Medical Foundation (PAMF) patients. They are saved as Acrobat files to retain the format of the form.

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Types of Forms:

• AB1455 Claims Settlement
• Advance Health Care Directive
• Health Care-Patient Partnership
• Imaging/Radiology Form
• Medical History Forms
• Personal Medical Records
• Sports Screening Questionnaire

AB1455 Claims Settlement

Practices & Dispute Resolution Mechanism

As required by Assembly Bill 1455, the California Department of Managed Health Care has set forth regulations establishing certain claim settlement practices and the process for resolving claims disputes for managed care products regulated by the Department of Managed Health Care. This information notice is intended to inform you of your rights, responsibilities, and related procedures as they relate to claim settlement practices and claim disputes for commercial HMO, POS, and, where applicable, PPO products where Palo Alto Medical Foundation is delegated to perform claims payment and provider dispute resolution processes.

AB1455 Claims Settlement Practices & Dispute Resolution Mechanism (Acrobat file)
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Advance Health Care Directive

You may obtain an Advance Directive form from your provider to discuss and complete. If you would like a free consultation with a trained volunteer to discuss the form, please call (650) 853-2960 to arrange an appointment at our Palo Alto facility or (510) 623-2231 at our Fremont facility.

• California Advance Health Care Directive Form (Acrobat format) -- print and complete
  
• Directiva Por Anticipado De La Atencion De La Salud -- Spanish version (Acrobat format)

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Health Care-Patient Partnership

Please download and sign this form to join the PAMF Patient Partnership Program designed to help with the management of chronic health conditions.

Your participation in this program allows PAMF to use your personal health information to prompt automated telephone calls that will remind you of appointments, lab tests or other health maintenance recommended for the care and management of your chronic health condition.

Give this form to your primary care physician, or send it directly to PAMF Quality and Planning,

Patient Partnership Program
795 El Camino Real
Palo Alto, CA 94301

PAMF Patient Partnership Program Form (Acrobat file)
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Imaging/Radiology Form

Authorization for use or disclosure of imaging information

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Medical History Forms

Pediatrics Medical History Form

Adolescent Medical History

Adolescent Parent/Guardian Form

Adult Medical History Form

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Personal Medical Records

Please open the necessary file below, print and complete the form.

Form: Request for Release of Medical Records, $15 fee

The release form requires a pre-payment of $15.

Send by mail to:
PAMF Health Information Management
795 El Camino Real
Palo Alto, Ca 94301
or FAX: 650-838-1606

Form: Request for Access to Medical Record: $15 fee (only the immunization records are free of charge)

The access form requires a pre-payment of $15 (check made payable to ACTA Medical Services) -- please no FAXing; mail to:
PAMF Health Information Management
795 El Camino Real
Palo Alto, Ca 94301

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Sports Screening Questionnaire

School-Age Children and Teens

Sports Screening Form

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