Forms

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Policy and charges associated with completing forms  23k v. 2 May 15, 2014, 12:10 PM Daniel Zerbe
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Lechworth Family Medicine's Notice of Privacy Practices  20k v. 2 Sep 23, 2013, 8:10 AM Daniel Zerbe
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Summary of HIPAA Privacy Rule from the Department of Health and Human Services  Sep 23, 2013, 7:15 AM Daniel Zerbe
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New Patient Form Use this form before your first visit to organize your medical history information.  77k v. 3 Mar 8, 2012, 12:31 PM Daniel Zerbe
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Working Papers AT-16 Physical Fitness Certification  28k v. 2 Sep 25, 2012, 6:58 AM Daniel Zerbe
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DOT Physical form for Commercial Drivers; patient must complete page one BEFORE exam  414k v. 3 May 15, 2014, 12:05 PM Daniel Zerbe
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Permission form for other adults to consent to treatment for your child.  408k v. 2 May 4, 2013, 6:38 AM Daniel Zerbe
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Expanded Health History form for DOT Physicals; patient must complete prior to exam  310k v. 2 May 15, 2014, 12:09 PM Daniel Zerbe
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Parking Permit Application for those with disabilities  168k v. 4 Feb 18, 2012, 7:01 PM Daniel Zerbe
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School Physical Form  31k v. 3 Jan 31, 2012, 6:11 AM Daniel Zerbe
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Health Care Proxy Form and Instructions  88k v. 3 Feb 1, 2012, 7:14 PM Daniel Zerbe
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DNR Order Form for your home  9k v. 4 Feb 18, 2012, 2:02 PM Daniel Zerbe
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Permission to disclose your health information to others to be placed in your medical record   42k v. 5 Feb 18, 2012, 7:01 PM Daniel Zerbe
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Release for a Copy of Medical Records to be either sent from or sent to Letchworth Family Medicine  16k v. 4 Feb 18, 2012, 1:56 PM Daniel Zerbe
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FMLA certification form for employee medical conditions  163k v. 3 May 14, 2012, 2:42 PM Daniel Zerbe
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FMLA certification form for a family members medical condition  134k v. 3 May 14, 2012, 2:42 PM Daniel Zerbe
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Work Excuse form for patients to fill out for their employer.  174k v. 3 Apr 18, 2012, 5:22 PM Daniel Zerbe
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