Authorization to Leave Health Information by Alternate Means
Acknowledgement of Notice of Receipt of Privacy Policies
Member Services Guide
Clinic Financial, Payment & Other Policies
Authorization for Provider to Release Health Plan Information
Patient Registration and Insurance Assignment
Authorization to Disclose/Release Protected Health Information
New Patient Information
Influenza Vaccine Consent Form
DR. NLGD LLC Healthcare Practice
1660 South Alma School Road ▪ Suite 125
Mesa, AZ 85210
P 480.669.6452 ▪ F 888.977.3601
LEGAL - PRIVACY l COPYRIGHT © 2017 - 2018 l DR. NLGD LLC. ALL RIGHTS RESERVED.
Medical Appointment Cancellation Policy
Please take a moment to complete the 'Health Screening' form listed below as requested by our healthcare practice:
Advanced Health Care Directive
When properly integrated with a corporate wellness plan, screenings can help reduce health risks, improve health status, reduce health care costs, and improve productivity and performance of the workforce.
Healthcare Practice 'Providing High Quality Cost-Effective Healthcare To All'
Adolescent/Adult Medical History Information
Tetanus & Diphtheria Vaccine
Pediatric Medical History Information
Consent For Tuberculin Skin Test
Generalized Anxiety Disorder