A note from Dr. Lee
Credentials
Please fill out the information below and click submit.
PERSONAL INFORMATION:
NAME: *
EMAIL: *
Male Female *  
STREET: *
CITY: *
STATE: *
ZIP: *
HOME PHONE:
CELL PHONE: *
BIRTH DATE: *
PLACE OF BIRTH: *
AGE: *
SS#: *
DRIVER'S LIC. #: *
EMPLOYED BY:
ADDRESS:
CITY:
STATE:
ZIP:
OCCUPATION:
If not working, are you on disability?* yes no
Since (date)

   
INSURANCE INFORMATION:
PRIMARY INSURANCE:
INSURANCE NAME: *
INSURANCE TYPE:  
STREET:
CITY:
STATE:
ZIP:
PHONE: *
POLICY #: *
GROUP #: *
CERTIFICATE #
SUBSCRIBER #:
   
SECONDARY INSURANCE:
INSURANCE NAME:
STREET:
CITY:
STATE:
ZIP:
PHONE:
POLICY #:
GROUP #:
CERTIFICATE #:
SUBSCRIBER #:
   
NEAREST RELATIVE NOT LIVING WITH YOU:
NAME: *
RELATIONSHIP: *
PHONE: *
   
SIGNIFICANT OTHER:  
NAME: *
PHONE: *
   
WHO SHOULD WE CONTACT IN CASE OF AN EMERGENCY?
NAME: *
PHONE: *
   
*NOTE, YOUR INSURANCE IS A CONTRACT BETWEEN YOU, YOUR EMPLOYER, AND THE INSURANCE COMPANY. WE ARE NOT A PARTY TO THAT CONTRACT.

I UNDERSTAND AND AGREE THAT, REGARDLESS OF MY INSURANCE STATUS, I AM ULTIMATELY RESPONSIBLE FOR THE BALANCE ON MY ACCOUNT FOR ANY PROFESSIONAL SERVICES RENDERED. THERE WILL BE A 1.5% INTEREST CHARGE PER MONTH AND A 30% COLLECTION FEE FOR OVERDUE ACCOUNTS. I HAVE READ ALL THE INFORMATION AND HAVE COMPLETED THE ABOVE ANSWERS. I CERTIFY THIS INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

I AGREE TO THE ABOVE*

YES NO  
   
ASSIGNMENT OF INSURANCE BENEFITS
IF THERE IS INSURANCE COVERAGE FOR THIS PERIOD OF HOSPITALIZATION AND/OR PROFESSIONAL SERVICES, PLEASE FILL OUT THIS AUTHORIZATION AND IT WILL BE FORWARDED TO YOUR INSURANCE COMPANY FOR PAYMENT.
TO (INSURANCE COMPANY): *
STREET: *
CITY: *
STATE: *
ZIP: *
   
I HEREBY AUTHORIZE PAYMENT DIRECTLY TO THE BELOW NAMED PHYSICIAN AS INDICATED HEREIN OF ALL HOSPITAL OR PROFESSIONAL EXPENSE BENEFITS PAYABLE TO ME, BUT NOT TO EXCEED THE REGULAR CHARGES OF FEES FOR THIS PERIOD OF HOSPITALIZATION OR PROFESSIONAL SERVICES. I DO UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ANY AMOUNTS THAT ARE NOT PAID THROUGH MY INSURANCE COMPANY. INSURANCE IS BILLED ONLY AS A COURTESY. I UNDERSTAND THAT PROFESSIONAL SERVICES AND CHARGES ARE ULTIMATELY MY RESPONSIBILITY.

I AGREE TO THE ABOVE*
YES NO  
 
Contacts
How may we contact you with insurance questions, confidential lab results or general questions. (Please X all that apply)
    routine urgent
Email *
Home #
Work #
Cell # *
Pager#
Fax #
 
I do authorize to receive calls and/or correspondence at the above numbers and/or addresses*
Yes No    
 
Is there anything else you would like us to know about you?
 
DATE: