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Patient Forms & Notices

Patient Forms & Notices

All our hospital’s patient forms and notices are collected here in PDF form. These are the policies you will be asked to read before or after receiving medical treatment at our hospital. You will be asked to complete the forms after your visit here. 


Financial Assistance

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Plain Language Financial Assistance Policy
– EN
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Política de ayuda financiera de lenguaje sencillo
– ES
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Compliance Language Financial Assistance Policy
– EN
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Política de ayuda financiera de lenguaje de cumplimiento normativo
– ES
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Financial Assistance Application Form
– EN
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Formulario de solicitud de ayuda financiera
– ES
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Pricing Transparency 2019
– EN
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Pricing Transparency 2020
– EN

Price Transparency 2019 (Excel)

Patient Notices

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Notice of Privacy Practices
– EN
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Aviso de prácticas de privacidad
– ES
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Non-Discrimination Statement
– EN
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Declaración de no discriminació
– ES
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Patient Rights & Responsibilities
– EN
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Derechos y responsabilidades del paciente
– ES

Release Form

When you complete and sign this form, you give us permission to share your medical information with a specific healthcare provider.

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Authorization for Use or Disclosure of Patient Health Information
– EN
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Autorización de uso o divulgación de información de salud de un paciente
– ES
mlkch staff member helping guest filling out form

Find important information related to your privacy, our non-discrimination policy, and giving other people permission to see your health records.

HIPAA Notice of Privacy Practices

Patient Rights & Responsibilities

Non-Discrimination Statement

Notice of Charity Care & Fair Pricing

Medical Records Release Form

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