Submit the completed forms to Torrance Memorial Physician Network by mailing them to: 23326 Hawthorne Boulevard, Suite 200, Torrance, CA 90505. Alternatively, you can fax the forms to 310-517-1165 ext. 71165. For electronic submissions, use the provided online submission forms on the Torrance Memorial Physician Network website or email them to the designated contact. Ensure all fields are accurately completed to prevent any processing delays.

Ensure all forms are completed and submitted before your appointment dates in 2024 and 2025 to avoid any delays in medical treatment or insurance processing.

The purpose of these forms is to gather essential personal and insurance information from patients aged 18 and older for accurate record-keeping at Torrance Memorial Physician Network. Completing these forms ensures that the medical team has up-to-date information needed for providing the best care. Additionally, signing the agreement forms establishes patient consent for medical treatment and helps patients understand their financial responsibilities.

• 1. Patient Information: Includes fields for full name, date of birth, sex assigned at birth, primary language, and contact details.
• 2. Emergency Contact: Details for an emergency contact, including their name, relationship to the patient, and phone numbers.
• 3. Employment Status: Information on the patient's employment status, employer details, and occupation.
• 4. Primary Insurance: Fields for primary insurance information, including company name, member ID, group number, and subscriber details.
• 5. Secondary Insurance: Fields for secondary insurance information, if applicable, similar to the primary insurance section.
• 6. Guarantor Information: Details of the person responsible for the bill, including their full name, relationship to the patient, and contact information.
• 7. Acknowledgment and Consent: Sections for the signature of the patient or patient representative to acknowledge and consent to privacy practices and financial agreements.

Failing to submit these forms can lead to delays or refusal of medical treatment and insurance processing issues.

• Treatment Delays: Without completed forms, your medical treatment may be delayed as essential information will be missing.
• Insurance Issues: Incomplete forms can result in problems with insurance billing and claims processing, potentially leading to denied coverage.
• Inaccurate Records: Failure to provide updated information can lead to inaccurate medical records, affecting the quality of care received.

• 1. New Patient Registration: Complete this form to provide necessary information for creating a new patient record.
• 2. Update Information: Use this form to update any changes in your personal or insurance information.
• 3. Acknowledge Privacy Practices: Acknowledge receipt of Torrance Memorial Physician Network's privacy practices.
• 4. Agree to Financial Policies: Sign to agree to the financial responsibility policies and assignment of benefits.
• 5. Consent for Treatment: Provide consent for medical treatment and the release of information by signing the form.