Dear New Patient,
I am looking forward to meeting you and helping you attain your best health possible! Please carefully read and fill out these forms at your convenience prior to your appointment and fax them back to us at 760-465-2332 or mail them to 477 N. El Camino Real Ste. D200, Encinitas, CA 92024. (Note: You can save the document to your desktop and open it in Adobe Reader to type directly onto the document. Click the "Fill and Sign" button after saving it to complete the form.)
To be eligle for TeleHealth sessions, please also include this document.
If you wish to receive information about upcoming appointments from our automated patient notification system, please complete this form.
On this page you will find a map to locate our office. As part of the above forms, we have enclosed a Record Release Form for additional records that you feel would be important. If there are any recent labs, imaging studies or doctor notes that you think may be important, please try to have these made available to us at the time of your appointment. Send the Release of Medical Records form to your referring doctor.
Please use our Center for Hormonal Health and Well-Being Medical Records Release Form if you wish us to release medical information to another provider.
If you need to cancel or reschedule your appointment for any reason, please give us 48 business hours notice. It is our policy to charge for appointments that are missed or those not canceled within 48 business hours. Insurance does not cover these charges.
Patients using insurance plans will be required to have a credit card held on file to make payments for insurance benefits denied, deductibles not met, or inaccurate copay payments. Once Dr. Weiss has received an EOB (explanation of your benefits), your credit card will be charged for any of the above deficiencies and a statement (aka EOB) from your insurance company will detail these charges. If there has been an over payment on your copay or fee, your account will be refunded.
All Co-pays are due upon check-in. Click here for a list of insurance plans we accept. We do not accept United Healthcare, Health Comp HMO or Medi-Cal: California Medicaid welfare program. If you have an EPO plan, please contact your insurance provider to determine if they will cover our services. Credit cards, checks or cash are accepted and we will give you a receipt. Medicare patients will need to complete the Advance Beneficiary Notice of Noncoverage (ABN) form for non-covered services (page 9 of our New Patient packet).
The first visit and subsequent follow-up visit are critical for establishing the best care possible. Please know that if I order labs, imaging or any procedure, I will expect you to return to the office to discuss these results and further treatment considerations in person. After the second office visit, you may request a phone consultation. Phone consultation service charges will apply.
For prescription refills or renewals, please contact your Pharmacy at least 48 hours in advance, so they can fax or electronically send us their forms.
If you choose to communicate with us via email, please know that this form of communication is not HIPAA compliant unless it is done within Practice Fusion's patient health record.
Lastly, we look forward to meeting you. Our goal is to build a true partnership with you!
In Best Health,
Danielle Weiss, MD, FACP