Patient Membership Forms
Thank you for your interest in joining us at Placer Private Physicians! We are excited to offer you a smaller and more personalized primary care practice, more convenient and direct communication with your physician, and more time to focus on the healthcare needs of you and your family. Unfortunately, at this time our practice is full and we are no longer accepting new patients (as of July 2021). Please call the office if you would like information regarding being added to our wait list.
Below you will find the membership forms necessary to register as a member of our practice:
- PLACER PRIVATE PHYSICIANS PATIENT SERVICES AGREEMENT
- Release of Medical Records
- Release of Medical Records to Family Members
- Privacy Policies
- New Patient Health Questionnaire (download to your computer to fill out the form electronically)
- Ethnicity and Race Specification Form
- Chronic Opiate Therapy Declaration
Please be sure to list all the members of your family who will be joining along with their appropriate information. Please note, it is important that all adult members sign the Patient Services Agreement. When you register on Hint Health, you will be able to sign the forms electronically online, but we need to have a signed paper copy on file with your information at our office as well.
Payments to our practice are made through Hint Health. Payments can be made by ACH direct from your checking account, or also via credit card or ATM debit card. When you sign up for our practice, you will enter your information by following the link to Hint Health. There you can specify monthly, quarterly or annual billing schedule, as well as what time you would like your membership charged each month. Note there is a 5% discount for memberships paid annually. Their system will automatically manage your payments. There is a 90 day non refundable fee that covers your first three months of membership, after that, you can cancel your membership at any time.
The Privacy Policies page is for your records, please do not return it.
You may choose to mail, fax, or scan and email the forms back to us.
Once again, thank you for joining Placer Private Physicians and we look forward to serving you and your family!
Placer Private Physicians
6960 Destiny Drive
Rocklin, CA 95677