Pre-Registration Step 1 of 4 25% Choose your NAMG Location:*BanningCoronaHemetMenifeeMoreno ValleyNorco/EastvalePalm DesertPalm SpringsRiversideSan BernardinoTemeculaWildomarPatient Information:Name* First Last Middle Initial Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Social Security Number Sex Male Female Date of Birth MM slash DD slash YYYY Marital StatusMarriedSingleDivorcedEmployment StatusFull TimePart TimeRetiredMedical LeaveDisability LeaveEmployer Name Employer PhoneOccupation Spouse/Family InformationSpouse Name First Last Date of Birth MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneSex Male Female Marital StatusMarriedSingleDivorcedEmployment StatusFull TimePart TimeRetiredMedical LeaveDisability LeaveEmployer PhoneOccupation In case of an emergency, please notify: Relationship to Patient Insurance InformationMedicare Number MediCal Number Other Insurance InformationPolicy Holder Name Subcriber ID Insurance Company Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneGroup Name Policy Number Group Number Secondary Insurance InfoPolicy Holder Name Subcriber ID Insurance Company Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneGroup Name Policy Number Group Number By entering your full legal name below, you hereby give permission to Nephrology Associates Medical Group Inc. to render treatment: Medical HistoryPlease check all that apply to you:Kidney Disease CKD Trasplant Dialysis Polycystic Kidney DZ Acute Kidney Injury Glomerulonephritis None of the Above Cancer Lung Breast Prostate Colon Melanoma Bladder Lumphoma Kidney Thyroid Leukemia Pancreatic Other None of the Above Diabetes Type I Type II Type Unknown None of the Above High Blood Pressure Essential Renovasular White Coat Yes, but not sure on type None of the Above Ischemic Heart Dz Heart Attack Angina Angloplasty Coronary Stent CABG None of the Above Stroke Yes No Gout Yes No EENT Blindness Cataract Hearing Problem Glaucoma Other None of the Above Cardiovascular Atrial Fibrillation Pacemaker AICD Valvular Heart Dz CHF Mitral Valve Prolapse None of the Above Respiratory COPD Chronic Bronchitis Asthma Emphysema Pneumonia Tuberculosis Sleep Apnea None of the Above Gastrointestinal GERD Stomach/Bowel Ulcers Gall Bladder Hepatitus Inflammatory Bowel Dz Irritable Bowel Syndrome Gluten Intolerance Lactose Intolerance None of the Above Genitourinary Enlarged Prostate Kidney Stones Frequent UTIs None of the Above Musculoskelatal Arthritus Osteopososis Back/Spine Problems None of the Above Neurological Multiple Sclerosis Seizure Parkinson's Dementia None of the Above Psychiatric Depression Anxiety Other None of the Above Endocrine Hypothyroidism Hyperthyroidism Adrenal Insufficiency None of the Above Hemotology Anemia Sickle Cell Disease Sickle Cell Trait Blood Transfusion Thalassemia None of the Above Immune/Allergy HIV AIDS Rheumatoid Arthritis Lupus None of the Above Surgical HistoryHave you had surgery? Yes No When did you have surgery? MM slash DD slash YYYY What type of surgery? Appendectomy CABG Carotid Endartarectomy D&C Gail Bladder Removal Gastric Bypass Hemorrthoidectomy Hernia Repair Hip Replacement Knee Replacement Hysterectomy Prostatectomy Nephrectomy Renal Transplant Thyroidectomy Tonsillectomy Valve Replacement AV Fistula AV Graft PD Catheter Other Family HistoryKidney Disease Father Mother Sibling Child None of the Above Diabetes Father Mother Sibling Child None of the Above High Blood Pressure Father Mother Sibling Child None of the Above Stroke Father Mother Sibling Child None of the Above Gout Father Mother Sibling Child None of the Above Polycystic Kidney Disease Father Mother Sibling Child None of the Above Demenia Father Mother Sibling Child None of the Above Family StatusFather Living Deceased Unknown Mother Living Deceased Unknown Social HistoryMarital Status Married Single Divorced Seperated Widowed Living Arrangement Alone Spouse Significant Other Family In Home Caregiver Assisted Living Facility None of the Above Occupation Retired Employed Unemployed Student Functional/Cognitive No Impairment Memory Deficit Hearing Loss Poor Vision/Blindess Limited Mobility Transportation Challenges None of the Above HabitsTobacco Use Never Used Current User Former User Tobacco Use: Year Started Tobacco Use: Year Quit (Leave Blank if Still Using) Tobacco Use: Type Cigarette Cigar Pipes Chewing Tabacco Snuff Alcohol Use Never Used Current User Former User Alcohol Use: Year Started Alcohol Use: Year Quit (Leave Blank if Still Using) Alcohol Usage Occasional social drink 1-2 drink/day 3 or more drinks/day Recreational Drug Use Never Used Current User Former User Recreational Drug: Year Started Recreational Drug: Year Quit (Leave Blank if Still Using) Recreational Drug Use: Types Marijuana Heroine Cocaine Barbiturates Amphetamines Ecstasy LSD Opium Other None of the Above Review of the SystemConstitutional Fever Weight Gain Weight Loss Fatigue Chills Weakness None of the Above HEENT Vision Impairment Eye Pain Redness Color Blindness Double Vision Hearing Loss Ear Pain Sinus Problems Sore Throat Nose Bleeds Headache Hoarseness Tinnitus Vertigo None of the Above Respiratory Shortness of breath Shortness of breath at rest Shortness of breath with activity Pain with breathing Cough Wheezing Blood in Sputum Night Sweats None of the Above Cardiovascular Chest Pain Palpitations Claudication Orthopnea Edema Parosyxmal Nocturnal Dyspnea None of the Above Gastrointestinal Abdominal Pain Nausea Diarrhea Heartburn Vomiting Constipation Anorexia Trouble Swallowing Indigestion None of the Above Genitourinary Urinary Urgency Urinary Burning or Pain Blood in Urine Urinary Frequency Urinary Hesitation Foamy Urine Incontinence Nocturia None of the Above Musuloskeletal Back Pain Neck Pain Muscle Pain Arm Weakness Leg Weakness None of the Above Skin Rash Itching Scaling Dryness Color Change None of the Above Endocrine Heat Intolerance Cold Intolerance Excessive Thirst None of the Above Psychiatric Depression Insomia Anxiety None of the Above Hematology Bleeding Gums Easy Bruising None of the Above Immuno/Allergy Seasonal Allergies Hives None of the Above Terms and ConditionsMEDICARE / MEDI-CAL / PRIVATE / HMO I request that payment of authorized Medicare and/ or other insurance carrier benefits be made on my behalf to Nephrology Associates Medical Group, inc. (Dr. David Chang, Dr. Darshan Dhiman, Dr. Paul Huynh, Dr. Taher Khalil, Dr. Joseph Lee, Dr. Paul Niu, Dr. Yogesh Patel, Dr. John Robertson, Dr. Chao Sun, Dr. Weng-Lih Wang, Dr. Jay Agarwal, Dr. Howard Erlanger, Dr. Arthur Galoustian, Dr. Jay Agarwal, Dr. Joseph Sanchez, Dr. Salem Ishak and Theresa Payne, N.P.) for any services furnished to me by that supplier/ physician. I authorize you to release any medical information about me that needed to determine these benefits or the benefits payable to related services to the Health Care Financing Administration and / or my other insurance carrier and its agents. I understand my signature requests that payments be made directly to the physician and also authorizes the release of medical information necessary to pay the claim. If item 9 of the HCFA-1500 claim form is completed, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare carrier of the full charge. I understand the Coinsurance and deductibles are based upon the charge determination of the Medicare carrier. I do hereby accept financial responsibility for all charges incurred by me. I understand that I am responsible for any charges not covered by my insurance companies and agree to provide a referral for each viyit, pay any co-payments, Medi-Cal share of costs, or annual deductibles that apply. I also understand that in the event that I fail to provide Nephrology Associates Medical Group, Inc. with the necessary information to bill my insurance company, or fail to inform them of any changed in my insurance coverage that I will be billed and held liable for the charges. Medical Release Consent As per the HIPPA Guidelines and Regulations, Nephrology Associates may release medical information only upon written authorization of the patient. For parent or guardian proof of guardianship is required. Patient is to sign and verify relationship upon release. Patient is responsible for medical information being released to other than a family member. I authorize Nephrology Associates Medical Group to release any necessary information if being referred to any other doctors or for necessary authorization and scheduling any type of procedure. Acknowledgement of Receipt of Notice of Privacy Practices I hearby acknowledge that I received a copy of Nephrology Associates Medical Group, Inc.\'s Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that I will be offered a copy of any amended Notice of Privacy Practices at each appointment.Do you agree with these terms and conditions?* Yes No CommentsThis field is for validation purposes and should be left unchanged. Δ