LEE H. COLONY, M.D., F.A.C.S.
To confirm that you accept the information above, please enter your initials between two slashes into the box below. Example: John Doe would enter /JD/
Are you allergic to any medications? If so, please list them and describe your reaction:
Please list any and all prescription, non-prescription , and over the counter medications, home remedies, vitamins, birth control pills, inhalers, etc. that you currently take.
Select any problems a family member has had an indicate your relationship.
Please make a mark next to any of the following persistent symptoms you have had in the past few months. Read through every section and check “No Problems” if none of the symptoms apply to you. If you have symptoms that are not listed, please list them on the space provided below.
The patient requesting care is responsible for payment. Copayments and deductibles are due at the time of service.
I hereby authorize release of information necessary to file a claim with my insurance company and assign benefits otherwise payable to me to the doctor or the corporation as indicated on the claim. A copy of my signature is as valid as the original. I certify that all of the demographic, medical, and insurance information is complete and correct.
In connection with the plastic surgical services which I am receiving from Dr. Lee Colony, I consent that photographs, videos, or other images may be taken of me or parts of my body, under the following conditions:
To our patients – This notice describes how health information about you, as a patient of this practice, may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPPA).
Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information.
We realize that these laws are complicated, but we must provide you with the following important information:
The following circumstances may require us to use or disclose your health information:
If you have any questions regarding this notice or our health information privacy policies, please contact Administrator – Dr. Lee H. Colony, 2900 Hannah Boulevard, Suite 110, East Lansing, Michigan 48823 or by telephone 517-333-4960.
I hereby acknowledge that I have been presented with a copy of Dr. Lee H. Colony – Michigan Plastic Surgery – Notice of Privacy Practice
Notice of Privacy Practices
Dr. Lee Colony, M.D.
Patient Financial Policy
Phone: 517-889-1297 || Fax: 517-333-5970