Patient Forms

Below, please find our downloadable and printable forms for authorization, medical record release and new patient information.

These forms may be dropped off, mailed or faxed to our office. Please do not email these forms for security reasons.

To process these forms in a timely manner, please complete all required fields. Contact our office at (616) 396-6516 with any questions.

Address: 382 N. 120th Avenue, Holland, MI 49424
Fax Number: (616) 396-2513

*Please note that we require a photo ID and a signed form in order for parents or guardians to access a minor’s (children under age 18) health records.

Authorization Forms

Authorizing Form Completion

This authorization allows our office to complete forms on your behalf such as Family Medical Leave Act, disability, handicap stickers, school/sports forms or employer forms. Please allow for up to 5 business days for our office to complete the form and note that there may be a fee.

Download Authorization for Completion of Forms

Authorizing Release of Medical Records

This authorization allows Lakewood Family Medicine to send any of your medical information anywhere (i.e. employer, school, transfer to new PCP). Please allow 10 business days for records to be sent.

Download Authorization for Release of Medical Records

Forms for Patients Turning 18

Now that you are 18 or older and no longer a minor, the Health Information Portability and Accountability Act (HIPAA) prohibits us from sharing your health information with your guardian or parent without written authorization. You may complete the following forms if you would like us to speak with your guardian or parent about your health records or have them pick up any written information such as copies of records or letters. You are able to change who you allow to access your information at any time.

Authorization for Release of Medical Information

This form tells LFM who may pick up written information on your behalf. Please note that this form must be completed yearly.

Download Authorization for Release of Medical Information

Protected Health Information Disclosure Preference - Confidentiality Form

This form tells LFM who they may speak with over the phone about your medical records and health information.

Download Protected Health Information Disclosure Preference – Confidentiality Form

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