You will need Adobe^® Acrobat reader to view and print out the forms. If you do not have a reader, you can obtain a free copy through this link.

New Gynecologic Patients Will Need These Forms

• Intake Form (63K pdf file, 2 pages)
• Registration Form (64K pdf file, 1 page)
• Loma Vista Financial Policy (13K pdf file, 1 page)
• Acknowledgment of Receipt of Notice of Privacy Practices Form (38K pdf file,
  1 page)
• Please note that the Acknowledgment of Receipt of Notice of Privacy Practices Form states that you have received and read the Notice of Privacy Practices (22K pdf file, 5 pages). Please download and read before completing the form. (The Notice of Privacy Practices is also available as a HTML page through this link.)

New Obstetric Patients Will Need These Forms

• Intake Form (63K pdf file, 2 pages)
• Obstetrical Screening (46K pdf file, 1 page)
• Registration Form (64K pdf file, 1 page)
• Loma Vista Financial Policy (13K pdf file, 1 page)
• Acknowledgment of Receipt of Notice of Privacy Practices Form (38K pdf file,
  1 page)
• Please note that the Acknowledgment of Receipt of Notice of Privacy Practices Form states that you have received and read the Notice of Privacy Practices (22K pdf file, 5 pages). Please download and read before completing the form. (The Notice of Privacy Practices is also available as a HTML page through this link)

Returning Gynecologic Patients Will Need These Forms

• Registration Form—This should be completed and signed once a year or when insurance, employer, address, or name has changed (64K pdf file, 1 page)
• Loma Vista Financial Policy (13K pdf file, 1 page)
• Acknowledgment of Receipt of Notice of Privacy Practices—If not already signed (38K pdf file, 1 page)
• Please note that the Acknowledgment of Receipt of Notice of Privacy Practices Form states that you have received and read the Notice of Privacy Practices (22K pdf file, 5 pages). Please download and read before completing the form. (The Notice of Privacy Practices is also available as a HTML page through this link.)

Returning Obstetric Patients Will Need These Forms            

• Obstetrical Screening (46K pdf file, 1 page)
• Registration Form—This should be completed and signed once a year or when insurance, employer, address, or name has changed (64K pdf file, 1 page)
• Loma Vista Financial Policy (13K pdf file, 1 page)
• Acknowledgment of Receipt of Notice of Privacy Practices—If not already signed (38K pdf file, 1 page)
• Please note that the Acknowledgment of Receipt of Notice of Privacy Practices Form states that you have received and read the Notice of Privacy Practices (22K pdf file, 5 pages). Please download and read before completing the form. (The Notice of Privacy Practices is also available as a HTML page through this link.)

Optional Forms/Information Pages            

• Authorization to Release Healthcare Information (289K pdf file, 1 pages)
• If you would like to have your medical records released, you are welcome to come by the office and fill out the form or you can either fax or mail it in.  If you fax or mail your request, you must include a copy of your drivers license or a photo ID for identity verification. Please allow AT LEAST one week to process your request.
• NOVASURE/Heavy menstrual bleeding questionnaire (19K pdf file, 1 page)
• Urinary tract infection instructions (19K pdf file, 1 page)

Updated 5/7/09

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Anjali Tate, M.D., Loma Vista Obstetrics & Gynecology
2577 Samaritan Drive, Suite 810, San Jose, CA 95124, 408.358.1888; Fax-408.356.0877. Email Dr. Tate

Notice of Privacy Practices - Copyright 2009, Anjali Tate, MD - Website by CommCraft.