Make sure all of the fields in red are completely filled out. The second page is only necessary if you are requesting the records be released directly to the patient or patient's legal representative. You may fax or mail this form to LMSC, Attn: Medical Records.
New patients and patient updates:
Please fill out all pages. If faxing back to our office, please include the patient's current insurance card. For anyone under the age of 18, fill out the "Minor patient packet" and include a shot record.