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.

This form can be downloaded from your computer. MyChart proxy access allows one person to access another person’s MyChart account. Typically, parents will use this to access their child’s account so they can schedule appointments check immunizations, request medications, and coordinate other health-related information for their child. Adults may also use it to access an older parent or relative’s record.

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.

Under the provisions of section 5112.17 of the Ohio Revised Code, Mercer County Community Hospital shall provide basic, medically necessary, hospital-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.