Please make sure to draw your signature where signature is required.
For Medical Records Request:
If you need to request records, please complete this form. Please note that there will be a charge for this request and per HIPAA laws and regulations you will be asked to provide a photo ID as well as documentation to show the right to the records requested. To complete the form after you have filled everything out, please click the SUBMIT on the top-right corner of the form. Once you have completed the form, someone from the Medical Records department will reach out to you ASAP. If you have any questions, please don’t hesitate to contact our main number at (479) 750-6632.
For the Notice of Election- Informed Consent:
Thank you for entrusting us to care for you and your family. Please note this form is choosing to elect the hospice benefit as well as providing you with the informed consent. Please make sure to complete the sections in red.
- Please make sure to complete the patient name at the top of page 1. Please make sure to put patient’s full name and DOB. This will then automatically complete in the other patient name and DOB sections.
- Please put the date you would like services to start in the Start of Care Date.
- Please note you have the right to choose an attending physician. Please check whether or not you would like to elect your own physician.
- Please make sure to sign on both pages 2 and 3.
- To complete the form after you have filled everything out, please click the SUBMIT on the top-right corner of the form.
Notice of Election – Informed Consent
If you have any questions, please don’t hesitate to reach out to our admissions office at (479) 872-3377.
