M.D. To Your Door
Leila Rhodes, M.D.
MEDICAL FORMS
Clinical
Form C-10 Health History Sheet.
Form C-16 Private Contract For Medicare Patients.
Form C-21 Request For Records Release.
Form C-28 Refusal of Treatment By Patient.
Form C-30 Generic Referral Slip.
Form C-33 Test Results Notice To Patient.
Form C-36 Osteoporosis Prevention Assessment Summary.
Form C-39 Laboratory Results of Practice.
Financial
Form F-12 Credit Card Acceptance.
Form F-23 Financial Policy.
Form F-24 Patient Encounter
HIPPA
Form H-2 HIPPA Privacy Authorization.
Form H-8 HIPPA Notice of Privacy Practices.
Insurance
Form I-1 Patient Insurance Registration.
Form I-1a Insurance Labels
Form I-4 Insurance Company Summary Sheet.
Form I-8 Medicare Claim Authorization.
Form I-9 Insurance Authorization.
Form I-10 Medicare Benefits Explained.
Form I-14 Patient Registration Update.
Form I-16 Insurance Plan Tracking Form.
Brochure
Business Cards
Physician's Note
