Patient Forms

Save time during your appointment

Complete the requsted form prior to your visit. Simply print the needed form, fill in the requested information, and bring the completed form to your appointment.

Patient Forms in English

Titanium Healthcare Patient Demographic Form

Titanium Healthcare Authorization to Release Information

Titanium Healthcare Past Medical History Form

Titanium Healthcare Patient Consent Form

Formularios para pacientes en Español

Titanium Healthcare Información Demográfica del Paciente

Titanium Healthcare Autorización para divulgar información

Titanium Healthcare Historia Medica Pasada

Titanium Healthcare Formulario De Consentimiento

Locations

Garden Grove
Tel: (714) 897-1071 | Fax: (714) 373-4696

Lakewood
Tel: (562) 925-7401 | Fax: ( 562) 925-8898

Downey
Tel: (562) 928-9700 | Fax: (562) 928 8300

Downtown Los Angeles
(Virtual visits only)
Tel: (213) 765-8123 | Fax: (213) 336-3032

Care Management

ECM California Helpline
Tel: (310) 280-5203

Washington Health Homes
Tel: (206) 926-3890

12566 Valley View Street
Garden Grove, CA 92845
Tel: (714) 897-1071

Member Resources
Report Fraud, Waste, and Abuse