Forms

To save time:

  • Please download the appropriate forms
  • Bring completed copies of the respective Forms to your appointment.

Note: You will need Adobe ® Acrobat reader to view and print out the forms which have been saved as .pdf files. If you do not have Adobe Acrobat reader, you can obtain a free copy through this link.

If you are a new patient:

If you want your medical records to be transferred:

For other specialized services:

Circumcision:

Ear Piercing:

Payments

We accept payment in the form of Cash, Check, Visa or Master Card.

As a courtesy to our patients, we bill most insurance companies. However, in the event of copayment, non-covered services, previous unpaid balances, etc., we require payment at the time of visit.

Please review below documents:

Billing

If you have questions with regards to billing, please contact our billing service at:

Keller’s Medical Billing Service
Mon – Thurs: 9AM – 4PM
Fri, Sat & Sun: Closed

Phone: (408) 323-2312
Fax: (408) 323-2314

www.kmbsinc.com

Insurance

Because we work with many insurance plans, we are unable to know the specifics of your particular plan. Please become familiar with the details of your insurance plan: structure (e.g. HMO, PPO, EPO, POS, etc.), type of coverage, and out-of-pocket costs (i.e. copayments, deductibles, non-covered services, etc.).

We also request that you bring your insurance card to every visit for verification. If you do not have the appropriate insurance information, you may be charged for the visit.

The list of insurance plans below are examples of accepted plans and subject to change without notice. Please check with your insurance company for the most up-to-date information.

PPO Plans

  Aetna   1-800-756-7039
  Amer-Net  
  BCE Emergis (BPS)   1-800-247-3315
  Beach Street   1-949-672-1398
  Blue Cross of California 1-800-765-4446
Blue Shield of California 1-800-424-6521
  CCN (First Health)  
  Choice Care (Humana)   1-800-626-2741
  Cigna   1-800-722-6059
  Cigna AIM  
  Cigna (Open Access)  
  Community Care Network   1-858-547-2502
  Corvel  
  Galaxy Health Network  
  Great-West (One Health)   1-800-663-8081
  Health Net   1-800-638-3889
  Interplan   1-209-473-0811
  Multi Plan
– Admar
– Health EOS
– Med Network
– AHC
– ForMost
– Health Network
– Preffered Plan
– ProAmerica
– BCE Emergis
  1-562-598-2266
 
  Nation Wide Health   1-800-226-5116
  Pacific Care   1-800-624-8822
  PacifiCare Health Alliance   1-916-366-5763
  PPO Net   1-805-582-9309
  Preferred Health Network   1-720-529-4400
  Private Health Care Systems (PHCS)  
  SaaGii  
  Tri-Care  
  United Health Care  
  USA Managed Care  
  USA Health Network   1-800-872-0820

POS Plans

 
  Aetna (PMG/ SCCIPA) 1-800-756-7039
  Aetna (USAccess)  
  Blue Cross of California (PMG) 1-800-765-4446
  Blue Shield (Access Plus) (PMG/ SCCIPA) 1-800-424-6521
  California Care (PMG)
  California Care (Direct Access) (PMG)
  Cigna (PMG/ SCCIPA) 1-800-722-6059
  Great-West (One Health) (PMG/ SCCIPA) 1-800-663-8081
  Health Net (PMG/ SCCIPA) 1-800-638-3889
  Pacific Care (PMG/ SCCIPA) 1-800-624-8822
  PHN Health Net Select (SCCIPA) 1-800-756-7039

EPO Plans


  Aetna (SCCIPA) 1-800-756-7039
  BCE Emergis (BPS) (PMG) 1-800-247-3315
  Blue Cross of California   1-800-765-4446
  Blue Shield of California   1-800-424-6521
  Health Net (PMG) 1-800-638-3889
  Nation Wide Health   1-800-226-5116
  PPO Net (SCCIPA) 1-805-582-9309
  United Health Care

HMO Plans

  Santa Clara IPA (SCCIPA)
  Physicians Medical Group (PMG)