Patient Forms - Epic
Thank you for choosing OhioHealth for your care. Below are some common forms used in our healthcare network. If you have any questions, please contact Ethics or Compliance at (866) 411-6181.
Financial Assistance Plan Summary
Communication providing an overview of OhioHealth’s financial assistance policy. Find additional financial assistance information on our website.
HIPAA Notice Of Privacy
Overview of individual rights with respect to personal health information. Find additional patient rights and regulatory information on our website.
Non Discrimination Statement
OhioHealth’s pledge to treat all people fairly without prejudice.
Patient Rights
List of basic rules of conduct between a patient and OhioHealth.
Medicare Rights (CMS)
Important information from the Department of Health and Human Services about rights as a Medicare covered Patient.
Medicare Outpatient Observation Notice
Notice to Medicare beneficiaries that are an outpatient receiving observation services and not an inpatient of the hospital.
Patient Safety Notice
Agreement for patients and visitors at OhioHealth to not wander facilities.
Hospital Consent
General agreement for a patient to receive in-patient, out-patient, or emergency services. This includes financial responsibility.
Telehealth Consent
What to expect during a telehealth visit and the responsibilities and actions to which the patient agrees.
Consent for a video visit of a minor child
An agreement by the guardian on the behalf of a minor to receive a video visit.
Medicare ACO
Explanation of what Medicare Accountable Care Organizations (ACO) are, how they work, your rights, and some general Q&A.