Fill Out All the Information Below

The completed information is passed to LBA HealthPlans, Inc. through a secured software application.

Family Doctor Online Information Form

Employee Information

First Name:
Middle Name:
Last Name:
Social Security Number
Date of Birth:
Street Address:
City:
State:
Zip Code:
Telephone Number (Home):
Telephone Number (Work):
E-Mail Address:
Employer Name:

Family Doctor Information (Employee's Family Doctor)

Doctor's First Name:
Middle Name:
Last Name:
Phone Number:
Fax Number:
Address:
City:
State:
Zip Code:
Current Patient?
How long have you been a current patient?

Spouse's Family Doctor

Spouse's Name:
Spouse's Birthdate:
Doctor's First Name:
Middle Name:
Last Name:
Phone Number:
Fax Number:
Address:
City:
State:
Zip Code:
Current Patient?
How long have you been a current patient?

Dependent(s) Family Doctor

Dependent's Name:
Dependent's Birthdate
Doctor's First Name:
Middle Name:
Last Name:
Phone Number:
Fax Number:
Address:
City:
State:
Zip Code:
Current Patient?
How long have you been a current patient?

Dependent's Name:
Dependent's Birthdate:
Doctor's First Name:
Middle Name:
Last Name:
Phone Number:
Fax Number:
Address:
City:
State:
Zip Code:
Current Patient?
How long have you been a current patient?

Dependent's Name:
Dependent's Birthday:
Doctor's First Name:
Middle Name:
Last Name:
Phone Number:
Fax Number:
Address:
City:
State:
Zip Code:
Current Patient?
How long have you been a current patient?

If more than 3 Dependents, list information here:

 
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