Patients and Forms
Click on each of the buttons below to quickly jump to different sections of this page, including our patient forms.
Information for New and Returning Patients
Elica patients can seek and receive interactive clinical advice by phone from our qualified “on-call providers” when the health centers are closed. For after hours care, please call: (916) 454-2345 FOR EMERGENCIES, DIAL 911
Patients are seen by scheduled appointment, although some same day visits are reserved for walk-in patients who present with serious symptoms.
Keep your appointment as scheduled or if you are unable to make your scheduled appointment, please call (916) 454-2345 to notify us and reschedule your visit. If possible, a 24 hour advance notice is preferred.
Convenient 24-hour access to personal health information is now available through a secure, on-line patient portal website. Please call or ask a member of our health center staff about setting up your portal account.
Patients, particularly new patients, should click and review the forms on this webpage to determine if they are required to complete and submit prior to or at their first appointment (forms are in PDF format and can be printed out and completed by hand). Forms are available for download on this webpage in English, Spanish, Russian, and Dari. Please download from the Patient Intake Packet section below.
All patients can apply for Elica's Sliding Fee Discount Program. To see if you qualify, please fill out the Sliding Fee Application which you can find in the Patient Forms section on this page.
Sliding Fee Discount Program
To help address financial barriers to accessing care for those who remain under-insured or uninsured, Elica offers a Sliding Fee Discount Program to those who qualify. The Sliding Fee Application is available for download on this page. If you are unable to show proof of income, please also download and complete the Self Declaration Form.
Our Sliding Fee Brochure is available in our Brochures section on this page.
Elica is a Patient Centered Medical Home
A Patient Centered Medical Home is a partnership between a provider-led health care team and an informed patient, which represents a better way to take care of your health needs and helps you manage your own care. It includes an agreement between the provider and the patient, which acknowledges the roles and responsibilities of everyone in the total health care program. Patient Centered Medical Home practices use evidence-based care.
What does Elica do as a Patient Centered Medical Home (PCMH)?
As a Patient Centered Medical Home, you may notice some differences in the way we provide care; however, most things will be familiar, including how we:
- Assign you a provider who knows you and your family, whenever they are available
- Provide you with care coordination across multiple disciplines to meet your medical needs
- Respect you as an individual
- We will not make judgments based on race, ethnicity, national origin, age, disability, sex, gender identity, religion and/or creed, and sexual orientation.
- Respect your privacy
- Your medical information will not be shared with anyone unless you give us written permission or if the law requires it.
- Deliver care using a team of people led by your provider
- Provide you with quality care when you need it, delivering it safely and in a manner that fits with your goals and values
- Take care of short-term illness and long-term disease, and give advice to help you stay healthy
- Tell you about your health and illness in a manner that you can understand
As your PCMH we will:
- Ask what your health care goals are, what you want to do to improve your health and help plan your care
- Use-evidence based care, and offer support for self management of your health
- Give you a written copy of the care plan
- Ask that you let us know if you can’t follow your care plan
- Remind you when tests are due so you can receive the best quality care
- Possibly offer you the option to join in a special type of visit called a “group visit.”
As part of our Patient Centered Medical Home orientation, we will ask you to acknowledge your agreement to the above, and we will acknowledge our promise to you.
What should I do as a patient?
We trust you, our patient to:
- Tell us what you know about your health, illnesses, needs, and concerns
- Take part in planning your care
- Follow the care plan that is agreed upon, or let us know why you can’t so we can try to help and adjust the plan
- Tell us what medications you are taking and ask for refills at your office visit when you need one
- Let us know when you see other doctors and what medications they prescribe or change
- Ask non-Elica providers to send us a report about your care when you see them
- Learn about your insurance so you know what it covers
- Keep your appointment as scheduled, or call at least 24 hours in advance to cancel your appointment
- Give us feedback so we can improve our services
Either you or your provider may end this partnership at any time. If you choose to end the partnership, please notify us and tell us why. If your doctor decides to stop seeing you, we will notify you with an explanation as to why. With written permission, we will forward a copy of your information to your next doctor.
Patient Forms
Patient Intake Forms (Used for All Elica Programs)
Other Forms That May Be Required For Your Visit (ask our staff)
Patient Brochures
Medicare Open Payments Information
For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.
The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov
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Medicare Open Payments Information
For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.
The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov
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