Medical Services Patient Registration
QMP Lynwood
3620 Martin Luther King Jr. Blvd.
Lynwood, CA 90262
Office: (949) 786-2004
Volunteers Of America, Hope Street
First Name
Last Name
Select Patient's Gender
Male
Female
Refuse To State
Date of Birth
Select Patient's Race
Asian
Black
Latino or Hispanic
Native American
Pacific Islander
White
Refuse To State
Select Insurance Coverage
option>
Accountable IPA
Aetna
AltaMed
Anthem BC
Blueshield
Blueshield Promise
Carelon
Caremore
Cash
CHDP
Cigna
Community Health
Employee
EPAC
GlobalCare
HCLA
Healthnet
Humana
HWLA
IEHP
Kaiser
LA Care
La Vida
Medi-cal
Medi-Medi
Medicare
Molina
No coverage
Omnicare
otherPrograms
Pacific Care
PI
PPO
PPP
PreferredIPA
PrepAp
Prudent buyer
SOFP
Tricare
UHC
Universal Care
WC
WellCare
Reason for appointment
Covid Testing
TB Testing
Sexual Transmitted Infection Testing
General Physical Exam
Other Healthcare Services
Accept Terms & Consent
I authorize my or (as a guardian, my ward, listed on this form as 'interest') healthcare information to be released to parties of interest, (ie Public Health Departments, Schools, Athletic programs, Daycare centers, Shelters and etc.). The release is intended solely for the purpose of assessing my covid-19 health status as it relates to my/interest participation.
The testing site or entity,
Quiclinics Medical Partners and/or their authorized affiliates
, make no guarantees that the information will not be redisclosed by recipient to a third party. Accepting this disclaimer/consent is voluntary but rejecting consent may affect condition under which service is provided. You may also revoke this consent at any time in writing.
By checking the box and/or proceeding, I certify that I have read the disclaimer and consented to the rules. This checked consent serves the same purpose as if it were a written consent, signed by the party.
Special note/direction