Patients
You now have seamless access to a comprehensive range of medical information, bringing together the expertise and services of our affiliated clinics and the advanced care offered at Lackey Memorial Hospital. This integration ensures that your health records and care details are conveniently consolidated, allowing for better coordination, enhanced communication, and a more holistic approach to your health.
Whether you’re visiting one of our clinics for routine care or receiving specialized treatment at the hospital, your medical information follows you, ensuring that your providers have the most accurate and up-to-date details to deliver personalized and effective care. This streamlined access empowers you to take charge of your health while fostering stronger connections with your healthcare team.
At Lackey Memorial Hospital, we are committed to making your healthcare journey as smooth and comprehensive as possible, prioritizing both convenience and quality in every aspect of your care.
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Patient Forms
For your convenience, we have provided the following forms to help you prepare for your initial visit to Lackey Memorial Hospital. Please print and complete all applicable forms and bring them with you to present at the reception desk when you arrive for your appointment.
Patient Information
Approved Representative
Conditions of Treatment
HIPAA Acknowledgement
Medicare Secondary Payer
PATIENTS REQUESTING MEDICAL RECORDS AND IMAGES
To request your medical records, please complete a Release of Information Authorization form (see below) and provide a photo ID. Please complete all sections of the form.
Release of Information Authorization Form
Formulario de Autorización para la Divulgación de Información Médica
Ways to request a copy of your medical records:
FAX a copy of your ID AND release form to 601-287-5170.
You may EMAIL a copy of your ID AND release form to ROI@lackeymemorialhospital.com. Please note that this email address only receives requests for medical records. You will not get an email response from this address.
MAIL a copy of your ID AND release form to:
Lackey Memorial Hospital
Attn: HIM Department
330 North Broad Street
Forest, MS 39074
On-site to provide a copy of your ID AND release form at:
LMH HIM Department
516 Airport Road
Forest, MS 39074
For billing information, please call the Business Office at 601-469-4151.
If you have other questions regarding medical record requests, please call 601-564-9320.
Ways to request a copy of images from Radiology:
FAX a copy of your ID AND release form to 601-333-0940.
MAIL a copy of your ID and release form to:
Lackey Memorial Hospital
Attn: MAC Radiology, Suite E
505 Airport Road
Forest, MS 39074
On-site to provide a copy of your ID and release form at:
MAC Radiology
505 Airport Road
Suite E
Forest, MS 39074
If you have other questions regarding imaging requests, please call 601-333-0977 or 601-333-0984.
PROVIDERS REQUESTING RECORDS
Please fax/mail/email your request on office letterhead/fax with patient and provider information. If images are needed, please contact Radiology. See the above contact information.
