New Patient Registration Form

This form includes personal information about you, insurance information, and gives us authorization to treat you and to bill and accept assignment for payment from your insurance company(s). Please download this form, complete and sign, and bring with you to your first visit.

Patient Portal

Authorization to Disclosure Medical Information

This form is used to give your authorization to SUDHA KARUPAIAH MD PC to release your medical records to another physician and/or organization, or to obtain your medical records from another physician and/or organization.

Medical Questionnaire

This form provides an overview of your medical history and family medical history to the physician and is instrumental in providing your physician with the information necessary for him/her to begin your patient/physician relationship. Please complete this form as detailed as possible, and bring it with you to your first visit.

New Office Policies

Notice of Privacy Practices

This form with your signature confirms that you have read and understood our Privacy Policy protecting your health information, please download and sign this form, and bring it with you at your first visit.

Privacy Practices

This document describes how medical information about you may be used and disclosed, and how you can get access to this information.

Medication History Authorization

By signing this form, you are giving permission to your doctor to access your prescription history

Sleep Questionnaire

This sleep questionnaire provides useful information for patients seeking help with sleep disorders. If you are scheduled for a sleep consultation, please print and bring this completed form with you for your first visit.

Department of Motor Vehicles Application for Disabled Person Placard or Plate

Download this form to apply for the Disabled Person Placard or Plate, and mail it to the Department of Motor Vehicles address is shown on the form.

DNR Form

A DNR is a request not to have cardiopulmonary resuscitation (CPR) if your heart stops or you have stopped breathing.

Health Care Directive

This form allows you to designate someone to make health care decisions for you when you are unable.

Physician Orders for Life-Sustaining Treatment (POLST) Form

Bring your insurance card. If you do not have your insurance card with you, you may be subject to being seen on a cash basis until proof of insurance can be established.

Bring the New Patient Forms mailed or emailed to you prior to your appointment. Please make sure they are completed prior to arrival. Please arrive 15 minutes prior to your scheduled appointment time to check-in.

Bring the actual bottles that any medication, vitamins, or supplements come in.

Please bring any relevant medical records which may assist the physician in understanding your medical conditions.

Dr. Sudha Karupaiah is contracted with Medicare, and HMO plans through the Santa Clara County IPA (SCCIPA), Affinity Medical Group, Premier Care IPA, and Physicians Medical Group (PMG). We are also contracted with most major PPO insurance plans

Patients with an HMO type of insurance who are referred for specialty care, must have an authorization for services prior to being seen. Patients with HMO insurance seeking a primary care physician (PCP) may select Dr. Sudha Karupaiah. This PCP selection must be made prior to being seen.

We are pleased to file your insurance claims on your behalf. Uncovered or denied services will be billed to you. Any copayments or deductibles related to your visit with us are due upon your arrival for the appointment. We accept cash, check, Mastercard, Visa, American Express, and Discover cards.

All of your medical records are confidential. You may designate other people to whom your medical records may or may not be disclosed. We will release the records or any part of them only if you give us written authorization. To cover administrative costs, copy fees for medical records are $15.00 plus 25 cents/page

To have prescriptions refilled, ask your pharmacy to contact our office electronically or by fax at (408) 279-3216, most prescription refill requests are handled the same day as received. To provide the best medical care, patients on long term medications are required to see their physician at least twice per year.