To become established with our office we ask that you print and fill out the PDF forms below. Once completed please return via fax, mail or drop them off to the office. Dr. Lee will personally review your forms and assign you to a provider based on your medical needs/history to conduct your initial visit. We will then contact you to schedule your initial appointment. Follow up appointments can be scheduled with a different provider on request.
Please remember to bring the following items to your appointment to ensure efficient and accurate care:
- Insurance card
- Government issued photo identification
- Co-pay or payment for any outstanding balance, which are due upon check-in
- Any other specific documentation that was requested by the practice
- List of all physicians you are seeing and their respective contact information
- Individual labeled original containers of any medications you are currently taking or using (prescription and over the counter bottles, ointments, creams, inhalers, etc.)
- Questions for your provider
- Pharmacy name, address, and telephone number
Forms to Complete Before Your Visit
1. Patient Forms
Authorization for Release of Medical Information (PDF) – Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.
Authorization and Consent for Treatment (PDF) – All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.
Preferred Contacts (PDF) – Patients are encouraged to complete and return the Preferred Contacts Form but it is not required.
2. Health History Questionnaire
Financial Policy (PDF) - This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.
Notice of Privacy Practices (PDF) - Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully. Aviso de prácticas de privacidad (PDF)