Lee & Soto Medical
399 E Highland Ave #223, San Bernardino, CA 92404 Tel: (909) 475-5200 | Fax: (909) 247-3219
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Documents



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