Online Forms

Click on the following links to download our online forms:

Patient History Questionnaire
Detailed 6-page form regarding past and current medical history for medical chart

Patient Information Form
Asks for demographics, insurance information etc. for business office

Request for Medical Records Form
Use this form to request copies of your medical records to be provided to another party

Authorization For Disclosure of Protected Health Information Form
Use this form to authorize LRDC to discuss your protected health information with another party, such as a spouse or child

Notice of Privacy Practice (HIPAA)
This notice provides information regarding how medical information about you may be used and disclosed

Employment Application Form
Access to this form requires some personal information prior to downloading. It is a 4 page form that all applicants for employment with LRDC must complete

Note: These forms have been made available in Adobe .pdf format. To view them, you must have Adobe Acrobat Reader installed on your computer. If you need to get it, you can click here and download the program for free from Adobe.