PATIENT INFORMATION SHEET (Please complete these forms prior to making an appointment!)
Obstetrics Biographical Information
Gynecology Biographical Information
Neurology Biographical Information
REQUEST FOR RELEASE OF MEDICAL RECORD
Request for Release of Medical Record (Lee)
Request for Release of Medical Record (Soto)
PERINATOLOGY CONSULT ICD 9 AND CPT CODES
Perinatology ICD 9 & CPT Codes
OB GYN PROCEDURAL CONSENTS
Circumcision
VBAC
Colposcopy, Cryotherapy, EMB, Leep
IUD Insertion
IEHP IUD & Implanon Consent
BTL in English (PM 330)
BTL in Spanish (PM 330)
BTL in English (Private)
BTL in Spanish (Private)
Hysterectomy (PM 330)
Hysterectomy (Private)
Hysterectomy (Office Form)
Depo Provera
NEUROLOGY PROCEDURE CONSENT
Lumbar Puncture
IEHP FORMS
Initial Perinatal Assessment (English)
Initial Perinatal Assessment (Spanish)
2nd Trimester Assessment
3rd Trimester Assessment
Postpartum Assessment
MEDI-CAL
Medi-cal Application
Medi-cal Application Instructions
List of Procedures Requiring Tar
Request for Medical Exemption -- you may complete this form to switch from an IPA to straight medi-cal.
STATE DISABILTY FORM (After completing the form, you can mail the form to the Disability Insurance Office nearest to your residence no earlier than 9 days --but no later than 49 days-- after the first day you became disabled.)
State Disability Form (de 2501)
Paid Family Leave / Newborn Bonding (de 2523f) -- you may complete this form after the initial 6-8 weeks of disability to get 6 more weeks of paid family leave.
OFFICE DOCUMENTS
Patient Sign-in Sheet
Lee's Termination Letter
Soto's Termination Letter
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