Patient Information & Forms

If your medical need is an emergency, please call 911 or visit your local emergency department.

For your first appointment, you will be asked to complete the following: 

• New Patient Information Form
• The Authorization For The Release of Protected Health Information Form

• We do not accept any assignment (direct payment) from any insurance including MediCal or MediCare for services provided through this private practice.
• Statements or insurance claim forms will be provided to you so that you may submit them to your insurance (or we can submit them on your behalf) for any eligible reimbursement from your insurance carrier to be paid directly to you.
• Please bring your insurance information with you to your first appointment.
• Please bring a picture ID to your first appointment.
• Fees are payable when services are rendered, contact our office for current fee schedule.
• A physician is on-call after hours and fees will be incurred (via telephone or online) when physician is requested after hours.  These fees are due and payable your next appointment.
• Reduced Fee Applications are available, Bring Two (2) Most Recent Paycheck Stubs or Most Recent Tax Return to be considered for a reduced fee for your initial visit.
• HIPPA privacy forms will also be completed at your first visit, per federal law.

Thank you for choosing Esano Corporation for your Mental Health Care!