(626) 915-9992

Castellanos Family Practice 

Patient Forms

We have several of our patient forms available here for you to download, print, and fill-out.
This will give you time to complete the information requested and will save you time on the day of your Covina healthcare clinic appointment.

Notice of Privacy Practices


In the process of providing medical care, Castellanos Family Practice collects and retains personal information concerning our patients. Castellanos Family Practice respects the privacy of your personal information and appreciates the importance of protecting this information by keeping it confidential and stored in a secure manner. Castellanos Family Practice employees are committed to maintaining the privacy and confidentiality of your protected health information, and wish to provide you with notice of our policies and procedures about privacy and confidentiality. This notice describes how Castellanos Family Practice has taken steps in accordance with federal and state laws to protect the confidentiality of the protected health information to carry out treatment, payment or health care operations, and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. We are required to follow the terms of this notice.

Protected Health Information:
"Protected Health Information” (PHI) is information that identifies you and relates to your identify and your past, present or future medical history. It includes your medical records and personal information such as your name, social security number, address, and phone number.

How we may Use and Disclose Your Protected Health Information For Treatment:
Information obtained by our nurses, physicians, or other members of your health care team will be recorded in your medical record and used to help decide what care may be right for you. We may also share this information to facilitate referrals or transmit critical information to other treating physicians or specialists, nursing facilities, laboratories, radiology, or related facilities that provide care or perform diagnostic tests ordered by your physician. We may also share this information with agencies that provide services to you, such as pharmacies or apothecary shops.

For Payment:
We may disclose information to health plans to confirm health care coverage or to receive payment for services provided by your physician. This information might be shared with hospitals, insurance carriers or Medicare to determine eligibility for insurance coverage. Information provided to health plans may include your diagnosis, procedures performed, or recommended care.

For Health Care Operations:
This information may be used in connection with training of our health care providers and staff. We may use your medical records to assess quality and improve services. We may contact you to remind you about appointments, obtain payment, provide test results, or give you information about treatment alternatives or other health-related benefits and services. We may use and disclose information to conduct or arrange for services, including: 1) Medical quality review by your health plan; 2) Accounting, legal, risk management, and insurance services; 3) Audit functions, including fraud and abuse detection and compliance programs.

Notification of Family and Others:
Unless you object, we may release health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may tell your family or friends your condition and that you are in a hospital. In addition, we may disclose information about you to assist in disaster relief efforts. You have the right to object to this use or disclosure of your information. If you object, we will not use or disclose it.

Patient Forms & Office Policies

Financial Policy

Payment Due at Time of Service:
We deliver the finest care at the most reasonable cost to our Covina Family Practice patients, therefore payment is due at the time service is rendered unless other arrangements have been made in advance.Co - Payments and Deductible Deposits are due at the time of healthcare clinic service in accordance with your policy requirements. Thank you for understanding.

No Show/Missed Appointments:
There is a $20 charge for Missed Appointments. If your appointment is for a Physical Examination, Pre-Operative Appointment, or Pap Smear, the missed appointment fee is $40. You may call to cancel or re-schedule 24 hours in advance. This helps us avoid gaps in our schedule and helps up maintain availability of same-day appointments for patients who need urgent appointments.

Patient Billing:
For your convenience. we accept Cash, Visa, and MasterCard. We do not accept Checks. If you have questions regarding your account, please contact us at (626) 915-9992. Many times, a simple telephone call will clear any misunderstandings. If you have made a payment on behalf of your insurance and we later receive payment from your insurer, we will refund any overpayment.

Payment is due upon receipt of a statement from our office. Monthly statements after the first one will accrue a $10 billing fee per monthly cycle.

Agreement of Insurance Policies:
Please keep in mind that your insurance policy is a contract between you and the insurer. If your insurer does not process payment for your services within a reasonable period, we will have to look to the patient for payment. The patient will also be responsible for any non-covered or unpaid services rendered.

Form Fees:
We are happy to fill out any forms you bring in. If you have forms that need to be filled out by a medical provider, there will be a fee assessed. This fee will be determined by the complexity of the form and the time required to complete the form.