Patient Forms

In an effort to save time and make things easier for our patients, we have posted all the required admittance forms on-line. Please click on the documents below (PDF files) and print them.  Please bring the completed forms with you to your scheduled appointment.

If you have any questions, please contact ICCC at (352) 326-2224.

Forms and Brochures

• Patient Information & History
• Florida Patient Information
• Assignment of Benefits (Lady Lake)
• Assignment of Benefits (Leesburg)
• HiPAA Patient Privacy Notification
• NPP101 Transportation Assistance

ACS Registration

Receive day-to-day help and support from the American Cancer Society.  Patients who register will receive, by mail, a patient packet including programs and services available from ACS.

• ACS Patient Registration (Lady Lake)
• ACS Patient Registration (Leesburg)

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