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FOR REFERRING PHYSICIANS

Physicians, below you will find a series of documents in PDF form.

Download the form, open the form and print, fill in the necessary information and have your patient bring to their next appointment.

ORDERING SERVICES

This form is for ordering diagnostic tests that are provided by Foothill Cardiology.

TO FC

Please select from the list at right to download the form for the correct office location:

ARCADIA

COVINA

PASADENA

Information for PRE-TEST patients who will be undergoing Myocardial Perfusion PET Imaging.

FROM FC

Click to download the document

DOWNLOAD

OTHER FORMS

Request for Foothill Cardiology patient medical information to be released to outside sources.

FROM FC

Click to download the document

Medical Release Form – PATIENT RELEASE

DOWNLOAD

Request for patient medical information to be released to Foothill Cardiology.

TO FC

Click to download the document

DOWNLOAD

AUTHORIZATION FOR RELEASE AND / OR DISCLOSURE OF MEDICAL INFORMATION

Completion of these documents authorizes the disclosure and/or use of individually identifiable health information, asset forth below, consistent with the Confidentiality of Medical Information Act of 1981, Civil Code Section 56 et seq,concerning the privacy of such information.

© 2020 Foothill Cardiology Medical Group, Inc.

All rights reserved.

CONNECTIONS

COVINA

Phone: 626.915.4700

315 N. Third Ave.
Suite 207

Covina, CA 91723

Business/Admin:

Phone: 626.793.2885

3452 E Foothill Blvd.
Suite 130

Pasadena, CA 91107

PASADENA

Phone: 626.793.4139

625 S Fair Oaks Ave
Suite 215
Pasadena CA 91105

ARCADIA

Phone: 626.254.0074

289 W. Huntington Drive

Suite 401

Arcadia, CA 91007