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Forms

Forms
 

Consent for Treatment of a Minor

This form can be downloaded from your computer. If gives authorization to the individual taking care of your children to allow emergency treatment in case it is needed.

Download form (8kb)

 

Universal Medication Form

Download this form to keep track of your medications, dosages, and allergies. You can keep this on file within your computer (Adobe Reader required) and print it out for your next visit to your doctor or to the hospital. You can also click the button on the bottom of the page to submit it securely to Mercer Health. Check to make sure the information is correct. Be sure to update this form as your medications change.

Download form (72kb)

 

Personal Health Record

Once this form has been downloaded on your computer, you can fill it out within Adobe Reader and print to bring in to your next visit, or click the button on the bottom of the page to submit it securely to Mercer Health. Check to make sure “Personal Health Record” information is correct.

Download form (684kb)

 

Authorization for Use and/or Disclosure of Protected Health Information

This form authorizes Mercer County Community Hospital to use and/or disclose protected health information in the manner described below and is voluntary. Community Hospital will not condition treatment, payment, enrollment or eligibility for benefits on the execution of this Authorization. The information used or disclosed as a result of this Authorization may be subject to redisclosure by the person or entity receiving such information, and no longer protected by the federal privacy regulations.

Download form (295kb)

 

Hospital Care Assurance Program (Free Care) and Charity Care
Program (Discounted Care) Policies:

Under the provisions of section 5112.17 of the Ohio Revised Code, Mercer County Community Hospital shall provide basic, medically necessary, hosptial-level services free of charge to any non-Medicaid Ohio resident, who is either covered by Disability Assistance or has a family income at or below the Federal Poverty Guideline on the date of service.  Click here to learn more about this program.

Download form (111kb)

 

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