Stockdale Radiology - New Patient Forms

4000 Empire Drive
Bakersfield, California 93309

P. (661) 631-8000

New Patient Forms

Download New Patient Forms

(English) Patient Registration Form

When patients enter our care, they fill out this admission form with basic information like their medical history, contact information, emergency contact information, a designation of the party responsible for payment and information about insurance billing if the patient carries insurance to cover health care expenses.

(Spanish) Patient Registration Form

Los pacientes completan este formulario de admisión con su información básica como su historial médico, información de contacto, información de contacto de emergencia, una designación de la parte responsable del pago e información sobre la facturación del seguro si el paciente tiene un seguro para cubrir los gastos de atención médica.

(English) Medical Release Form

The purpose of this request form is to give authorization for the release of medical images, reports, and records and to compare past treatments/surgeries and their effectiveness, as well as recent procedures. Records are confidential and cannot be disclosed without your written authorization, except when otherwise permitted by law.

(Spanish) Medical Release Form

El propósito de este formulario de solicitud es autorizar la divulgación de imágenes, informes y registros médicos y comparar tratamientos / cirugías anteriores y su efectividad, así como procedimientos recientes. Los registros son confidenciales y no se pueden divulgar sin su autorización por escrito, excepto cuando la ley lo permita.

(English) Physician-Patient Arbitration Agreement

The judiciary favors arbitration in healthcare as a cost-effective and efficient forum to resolve health-related disputes. By signing this contract, the signer is agreeing to have any issue of medical malpractice decided by neutral arbitration and you are giving up your right to a jury or court trail.

(Spanish) Physician-Patient Arbitration Agreement

El poder judicial favorece el arbitraje en el cuidado de la salud como un foro rentable y eficiente para resolver disputas relacionadas con la salud. Al firmar este contrato, el firmante acepta que cualquier problema de negligencia médica se resuelva mediante arbitraje neutral y usted renuncia a su derecho a un jurado o una pista judicial.

SRI Notice Of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

SRI Notice Of Privacy Practices (Spanish)

ESTE AVISO DESCRIBE CÓMO SU INFORMACIÓN MÉDICA PUEDE SER UTILIZADA Y DIVULGADA, Y CÓMO PUEDE OBTENER ACCESO A ESTA INFORMACIÓN. POR FAVOR, LÉALO DETENIDAMENTE

Patient Rights and Responsibilities

As A Patient at Stockdale Radiology, You Have the Right To: (View Doc)

Patient Rights and Responsibilities (Spanish)

Como paciente de Stockdale Radiology, usted tiene derecho a:

Financial Policy Intake

Thank you for choosing Stockdale Radiology for your imaging needs. We are committed to providing high-quality, patient-centered care and appreciate your cooperation with our financial policies. This policy outlines your responsibilities as a patient and how billing is managed.

Financial Policy Intake (Spanish)

Gracias por elegir Stockdale Radiology para sus necesidades de diagnóstico por imágenes. Estamos comprometidos a brindarle atención de alta calidad centrada en el paciente. Esta política explica sus responsabilidades financieras como paciente y cómo manejamos la facturación.

Patient Billing

At Stockdale Radiology, you can pay your bills online conveniently and securely. By clicking the button below, you will be redirected to the Per Your Health billing portal where you can enter the account number from your billing statement or your registered user ID to continue. If you have any billing questions, please contact us for further assistance.

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