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Patient Forms & Documents

Please fill out and bring to your first appointment

Patient Information Form
Change in Insurance
Medical Appointment Cancellation
MCM Patient Consent for Use and Disclosure of Protected Health Information
MCM Health History Form
MCM Authorization for Release and-or Disclosure of Medical Information
MCM Acknowledgement of Financial Policy and Patient Consent to Treatment

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Most major insurance plans accepted, including Medicare, Medi-Medi and Regal Medical Group plans.

At Media City Medical, we prioritize providing comprehensive healthcare services that are accessible to as many individuals as possible. As part of our commitment, we accept most major insurance plans, ensuring that our patients can receive the medical attention they need. Whether you are covered by Medicare, Medi-Medi, or Regal Medical Group plans, rest assured that our dedicated team of healthcare professionals is ready to assist you in navigating your insurance coverage.

Media City Medical
201 N. 1st St., Suite A
Burbank, CA 91502
Fax: 818-846-6222
Affiliated with Providence St. Josephs and Heritage Provider Network/Regal Medical Group.