PATIENT FORMS

 

Please print and complete the first form, Patient Demographics, and bring it with you to your first appointment.

 

We value and protect your privacy and confidentiality. As a patient, we encourage you to review our policies and notices:

FORMS

Patient Demographics

Privacy Practices

Bill of Rights and Responsibilities

Financial Acknowledgment

English                Spanish                 Hmong

TRANSFER MEDICAL & DENTAL RECORDS

 

Please fill out the following form and send to LCHC for consent to obtain/release your medical and dental records: Consent for Release of Records

 

FAX TO: 920-686-0352

EMAIL: Health Information Specialist

 

QUESTIONS?

Please Call 920-686-0453

 

*Once submitted, medical and dental records may take up to 30 days to transfer.

SHEBOYGAN: (920) 783-6633

MANITOWOC: (920) 686-2333

OUR MISSION:

Lakeshore Community Health Care provides access to comprehensive, integrated health care, regardless of  ability to pay, eliminating health disparities among the underserved.

Copyright © 2018 Lakeshore Community Health Care. All rights reserved.
Copyright © 2018 Lakeshore Community Health Care. All rights reserved.

English       Spanish       Hmong

English    Spanish   Hmong

Copyright © 2018 Lakeshore Community Health Care. All rights reserved.

English

Spanish

Hmong

English

Spanish

Hmong

English

Spanish

Hmong

English

Spanish

Hmong

Copyright © 2018 Lakeshore Community Health Care. All rights reserved.
Copyright © 2018 Lakeshore Community Health Care. All rights reserved.