Forms for All New Patients | Westside Head & Neck

We offer a few options for patients to submit their intake forms:

Print and fax: Print the New Patient Intake Form, fill out, and sign. Once you’re done, please fax these forms to 310-204-4474.
Email: Download the New Patient Intake Form, fill out, and sign. Once you’re done, please email to info@westsidehn.com
Fill out the forms online: Fill out and sign the form online. You can complete the online intake forms below and once you’re done, click ‘submit’ and it will automatically send to our team.
Drop off at your visit: Print, fill out, and sign the New Patient Intake Form and bring the completed forms to your appointment.

Please note: We will also need copies of your insurance card(s) at your first visit.

Fill Out the Patient Intake Form Online:

If you would like to fill out the intake form online, you can do so by completing and submitting the forms below. Once you click ‘submit,’ it will automatically send to our team:

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here at https://openpaymentsdata.cms.gov. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.

*As of October 1st 2023, Dr. Shapiro will be an out of network provider. Dr. Shapiro’s services will be fee-for-service and are not contracted with any insurance company. Payments are to be paid in full at the time of each visit or prior to the date of surgery. The fee schedule is available upon request. As a courtesy to our patients and to maximize your reimbursement, the office will provide you with a claim form to be submitted to your insurance. For out of network care we do not verify insurance coverage and assume the insurance information you provide is accurate. Reimbursements will come directly to you from your insurance carrier based on your plan's out of network coverage and deductible. We do not bill secondary policies. Please note that all other fees (facility and anesthesia fees for surgery, and tests such as labs or x-rays) will still go through your insurance as per regular insurance in-network contract.

COVID-19 ANNOUNCEMENT

At Westside Head & Neck, it is our highest priority to protect the health of our patients, staff, and community. As an essential business dedicated to serving the community, we will remain open with modified hours. We have implemented all guidelines set by the CDC and Department of Health with regards to ensuring safety and additionally installed state-of-the-art viral filtration systems in all rooms. Click here to read more.