PLEASE READ CAREFULLY BEFORE COMPLETING THE FORM
Thank you for entrusting us with your healthcare needs. We eagerly anticipate the opportunity to meet you and aim to surpass your expectations in every aspect of your behavioral treatment. Each member of the Pasadena Clinical Group team is dedicated to enhancing the quality of your care and ensuring a remarkable overall experience.
The provided form, referred to as UpPR (Update Payment Information), serves as a means to revise the payment details we have on record. This pertains to modifying your payment method(s), which may encompass your credit card details, third-party coverage, secondary insurance addition, and other sensitive particulars. This form facilitates the alteration of specific financial data, including payment methods, with certain exceptions.
In the United States, the Health Insurance Portability and Accountability Act (HIPAA) establishes guidelines for the disclosure of patient health information. HIPAA guarantees the safeguarding of patient information and its disclosure to authorized parties either with the patient's consent or as mandated by law. To release your information, we require written consent from you.
Kindly complete each section of the form to the best of your knowledge. Following submission, our staff will review it in the order it is received and process it within 1 to 5 business days. Please note that incomplete sections may hinder the processing procedure.
If you are updating payment information such as your credit card, you must be an authorized user of the card and provide a copy of your Driver's License or any other government-issued ID.
Attachments should be in PDF, JPG, or HEIC format. Regrettably, we cannot accept emails or other forms of verification.
Please allocate 3-7 minutes to complete the form.
Should you have any inquiries, feel free to contact our office for assistance at 626-354-6440. Our office hours are Monday through Friday, from 8 am to 7 pm.
There are three ways to complete the form:
1. Direct link
2. By scanning the QR code
3. By completing the form below