Member Forms
Looking for an advance directive or other form? You can download any of the forms below at no cost.
-
Health care privacy (ROI)
-
- Privacy Request Form (English PDF Opens In New Window | Español PDF Opens In New Window)
- Removal of Authorization Previously Given to Mercy Care (English PDF Opens In New Window| Español PDF Opens In New Window| العربية PDF Opens In New Window)
- Request for an Accounting of Disclosures of Protected Health Information (PHI) (English PDF Opens In New Window| Español PDF Opens In New Window| العربية PDF Opens In New Window)
- Protected Health Information (PHI) Access Request (English PDF Opens In New Window| Español (PDF)| العربية PDF Opens In New Window)
-
Advance Directives
-
- Living Will
- Health Care Power of Attorney (POA)
- Mental Health Care Power of Attorney (POA)
- Mileage/Food Reimbursement Form PDF Opens In New Window
- Pre-Hospital Medical Care Directive (Do Not Resuscitate)
- Authorization to Release Psychotherapy Notes (English PDF Opens In New Window| Español PDF Opens In New Window| العربية PDF Opens In New Window)
- Authorization to Release Protected Health Information (PHI) (English PDF Opens In New Window| Español PDF Opens In New Window| العربية PDF Opens In New Window)