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Get and Sign Patient Access Request for Medical Records Lee Health  Form

Get and Sign Patient Access Request for Medical Records Lee Health Form

Use a Patient Access Request For Medical Records Lee Health template to make your document workflow more streamlined.

All rights I have to preserve such records confidentiality. You may fax to (239) 939-6579 (Release of Information) or hand deliver to a LeeHealth facility. Patient’s Legal Name: Telephone: ( Date of Birth: ) Address: State: City: Zip: The information is to be: ❑ Mailed to ______________________________________; ❑ Picked-up Date: ______________________________ ❑ Electronic Delivery (additional form to be completed) The request is subject to the limitations as listed below and is for the...
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