TELEHEALTH ONLY
- Telehealth New Patient Forms - Fill forms out completely. They will be reviewed prior to scheduling.
- Medicare Form - Please sign if MEDICARE is your primary insurance.
DR. MICHAEL LE PATIENTS ONLY Please bring your INSURANCE CARDS and PHOTO ID to your office visit.
- New Patient Packet - Please bring your INSURANCE CARDS and PHOTO ID to your office visit.
- Medicare Advance Beneficiary Notice (ABN) - Please print and sign if MEDICARE is your primary insurance
- Las Formas en Espanol
- Formulario Medicare ABN en Español - Por favor imprima y firme si MEDICARE es su seguro primcipal.
| ALL OTHER PATIENTS Please bring your INSURANCE CARDS and PHOTO ID to your office visit. |
- New Patient Packet
- Medicare Advance Beneficiary Notice (ABN) - Please print and sign if MEDICARE is your primary insurance
- Las Formas en Espanol
- Formulario Medicare ABN en Español - Por favor imprima y firme si MEDICARE es su seguro primcipal.
HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA)
As required by HIPAA and California law, this practice may not use or disclose your individually identifiable health information except as provided in our Notice of Privacy Practices without your authorization.
- HIPAA / Notice of Privacy Practices
- Medical Records Release (Please complete this form if you need our office to release or request your medical records.)
- Consent to Disclose Medical Information - In order for our office to discuss your medical/billing information with anyone other than you, the patient; A form must be completed, signed, and handed to our office staff prior to any communication. THIS FORM MUST BE FILLED OUT IN PERSON, IN OUR OFFICE, BY THE PATIENT.
Map and Directions to Facilities