Patient Resources
Patient Forms
Print out the forms, fill them out, and bring it on the day of your visit.
Please click the links below to download our Registration Forms and Release of Information Form prior to arriving at our office. Please fill out and bring all forms with you.
In addition, please download and read the Notice of Privacy Practices Packet prior to your visit. Thank you.
- Patient Registration Form & Financial Agreement
- Patient Medical Intake Form
- Allergy Testing Charges Form
- Yearly Patient Update Form
- Authorization to Release Health Information Form
- Notice of Privacy Practices (Privacy Policy)
Medicare
If you have Medicare, please also download and fill out the Medicare Secondary Payer Questionnaire.
The files will open up as pdf files. You must have a pdf reader like Adobe Acrobat Reader to view.
Insurances We Accept
We accept the following insurance providers:
- Aetna (HMO/PPO)
- AARP
- Alliance
- Anthem
- Carefirst Blue Cross Blue Shield (HMO/PPO)
- Blue Cross Blue Shield Federal
- Blue Choice (HMO)
- Cigna
- NCPPO
- PHCS (Unicare)
- Medicare
- Mamsi / Optimum Choice/ MDIPA
- Tricare / Tricare Prime
- Humana
- Virginia Health Net
- United Healthcare
- Coventry Healthcare
- OneNet
- Trailblazers Medicare
Don't see your insurance?
Please call the office to check the participation status for Dr. James Lee and Dr. Vickie Lee in your health insurance plan.
Office Address
44320 Premier Plaza
Suite 110
Ashburn, VA 20147
Appointments: 703-723-8727
Inquiries: 703-723-8727