Patient Forms

Privacy Form
Financial Policy Form
Request for Correction Form

Patient Information

This form can be completed prior to your first appointment at LCA or if any of your personal information is updated.
Patient Information Form

Patient Medical History

This form can be completed prior to your first appointment at LCA or if any of your medical history has changed without LCA’s knowledge.
Patient Personal History

Release of Protected Health Information (PHI) to LCA

This release allows you to request that LCA obtain your medical records from any other health care professional(s) you have seen.
Release To LCA

Release of Protected Health Information (PHI) from LCA

This release allows you to request that LCA release your medical records to approved entities, such as your other health care professional(s), insurance companies, etc.
Release From LCA

Designation of Personal Representative

This form allows you to designate someone other than yourself to have access to and/or receive your Protected Health Information.
Designation of Personal Representative

Request for Restrictions

This form allows you to request that your protected health information (PHI) be restricted from review by other entities (e.g. Non-LCA health care professionals, insurance companies). Note: This request does not prevent LCA from releasing your records in the event of a subpoena.
Request For Restrictions Form

Request for Revocation of Restrictions

This form allows you to request that any previously placed restrictions on your Protected Health Information (PHI) be revoked.
Request For Revocation of Restrictions

 Request for Inspection

This form allows you to request permission to inspect your Protected Health Information (PHI).
Request for PHI Amendment Form

Request for Protected Health Information (PHI) Amendment

This form allows you to request that official documentation in your PHI (doctor’s notes, clinical records, etc.) be changed if you believe them to be erroneous.
Financial Policy Form

Request for Accounting of Disclosures

This form allows you to request an accounting of entities to which your Protected Health Information (PHI) has been released. Note: LCA does not account for disclosures to health care professionals. Release of PHI to insurance companies, legal entities, etc. is managed by our copy service, Southern Medical Document Solutions (SMDS). SMDS maintains an accounting of these transactions.
Request for Accounting of Disclosure

 Request for Confidential Communication by Alternate Means

This form allows you to request that LCA contact you by some means other than the standard methods (e.g. home/cell phone, home mailing address).
Request for Confidential Communication by Alternate Means