Mercer Health Personal Health & Medical Forms

For you and your loved ones’ convenience, we have compiled all of the most commonly used personal health and medical forms in one place. Simply click the button under the form you need and the download should immediately begin.

Having trouble downloading a form? Can’t find the resource you’re looking for?

Patient 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.

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MyChart Proxy Access Form

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.

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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.

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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, 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.

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Advance Directives

Advance Directives are legally binding documents that you can sign to specify the kind of treatment you desire or wish to refuse in the event that you are unable to express your wishes about your health care. Advance Directives include Living Will, Health Care Power of Attorney and Organ Donation. Information about Ohio’s Advance Directives is available online.

For more information about Advance Directives, including assistance in completing the appropriate forms, contact our Patient Advocate at 419-678-5615.