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R.O.A.D.S. Long Beach Clinic
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BELOW IS A LISTING OF PATIENT FORMS
After Hours Procedure (
English
|
Spanish
)
Agreement of Financial Responsibility (
English
|
Spanish
)
Application for Sliding Fee Discount (
English
|
Spanish
)
California Advance Health Care Directive (
English
|
Spanish
)
Consent for Treatment and to Disclose Records (
English
|
Spanish
)
DOWNLOAD ALL (ENG)
HIPAA Roads Foundation (Your Rights) (
English
|
Spanish
)
Informed Consent to Photograph (
English
|
Spanish
)
Patient Bill of Rights and Responsibilities (
English
|
Spanish
)
ROADS Patient Registration (
English
/
Spanish
)
Patient Sliding Scale Fee Survey (
English
|
Spanish
)
DOWNLOAD ALL (SPAN)
Roads
Roads Foundation
855-645-0033
info@roadsfoundation.org