Forms to complete prior to Outpatient or Inpatient care

• Important message from Medicare-English
• Important message from Medicare-Spanish

• Assignment of Benefits-English
• Asignment of Benefits-Spanish

If you have not already completed one and have it in your hospital record:

• Advance Directive/Living Will
• Advance Directive/Living Will in Spanish

General Patient Information

• Joint Privacy Notice-English
• Joint Privacy Notice-Spanish

• Patient Bill of Rights
• Patient Bill of Rights - Spanish

• Facility Directory-English
• Facility Directory-Spanish

• Facility Directory/Discharge Information
• Facility Directory/Discharge Information - Spanish

Medical Records/Health Information Management Forms

• Personal Medication Record
  
  
• Authorization for the Release of Patient Health Information
• Authorization for the Release of Patient Health Information - Spanish
  
  
• Authorization for the Request of Patient Health Information From Outside Health Care Providers
• Authorization for the Request of Patient Health Information From Outside Health Care Providers - Spanish
  
  
• Authorization for the Release of Psychiatric Health Information
• Authorization for the Release of Psychiatric Health Information - Spanish
  
  
• Request for Amendment of the Medical Record
• Request for Amendment of the Medical Record - Spanish
  
  
• Information Security and Privacy Complaint Form
  
  
• Sleep Disorders Referral Form
  
  

Financial Assistance

• Financial Assistance Income Questionnaire-English
• Financial Assistance Application-Spanish
  
  
• Financial Assistance Application Letter-English
• Financial Assistance Application Letter-Spanish
  
  

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