(951) 318-5396
255 North D Street, Suite 400 San Bernardino, CA 92401
info@diligenceintegratedcare.com
(951) 318-5396
255 North D Street, Suite 400 San Bernardino, CA 92401
info@diligenceintegratedcare.com
Patient Registration Form Click to Fill the Form Credit_Debit Card Collection Click to Fill the Form CONSENT FOR TREATMENT Click to Fill the Form Authorization to Release Medical Information Click to Fill theRead More
Go to the Forms Page by Filling Required Information…! Name* Email*
Read MoreGo to Back Please fill this form to send it to your Physician Standard Zych Form Intake ZD Patient Registration Form Patient Information First NameMiddle NameLast NameSexMarital StatusDate of Birth (Age)Social Security NumberPatient’sRead More
Go to Back Please fill this form to send it to your Physician Patient-Provider Policy Agreement Patient-Provider Policy Agreement Appointment PolicyAppointments may be scheduled by phone or online. If you are unable toRead More
Go to Back Please fill this form to send it to your Physician TREATMENT CONSENT FORM TREATMENT CONSENT I/we are providing consent forto receive treatment for (medical problem)with the following treatment(s): I/we understandRead More
Go to Back Please fill this form to send it to your Physician OFFICE POLICIES AND GENERAL INFORMATION Office Policies & General Information Office Policies and General Information Agreement to Provide Mental ServicesRead More
Go to Back Please fill this form to send it to your Physician CONSENT FOR TREATMENT CONSENT FOR TREATMENT I authorize and request that my provider at Diligence Care Plus carry out psychologicalRead More
Go to Back Please fill this form to send it to your Physician FEE AGREEMENT AS OF 08-21-2023 Fee Agreement We know that unexpected medical costs are one of the most common sourcesRead More
Go to Back Please fill this form to send it to your Physician HIPAA and Privacy Practices Notice HIPAA and Privacy Practices Notice This Notice describes how medical information about you may beRead More
Go to Back Please fill this form to send it to your Physician Credit/Debit Card Payment Consent Form Credit/Debit Card Payment Consent Form Financially Responsible Party:Middle NameLast NameName on Card if different: IRead More