Patient Forms

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Ohio Hills Health Services is a non-profit healthcare organization whose primary focus is to provide prompt, courteous, and affordable care to all patients, regardless of economic status, race, national, geographic, religious background, or political philosophy.

Below are forms which you might find useful.  If you wish to become a new patient of Ohio Hills Health Services, complete the Patient Application and return to the Health Center where you want to become established:

  • Barnesville Family Health Center
  • Caldwell Family Health Center
  • Freeport Family Health Center
  • Monroe Family Health Center
  • Quaker City Family Health Center

New patients should complete the following forms and bring them to your initial appointment:

  • Patient Demographic Form
  • Patient Contact Form
  • Patient Rights and Responsibilities Statement
  • Consent for Treatment and Payment Agreement
  • Authorization for Disclosure of Health Information

At Ohio Hills, we offer a Sliding Fee Scale. If you qualify, services will not be denied due to your inability to pay.  Please reference the Sliding Fee Scale Income Chart and the OHHS Sliding Fee Scale Application.

Patient Application (Fillable Form) (PDF)
Patient Demographic Form (Fillable) (PDF)
Patient Contact Form (Fillable) (PDF)
Patient Rights and Responsibilities Statement (Fillable) (PDF)
Authorization for Disclosure of Health Information (Fillable) (PDF)
Ohio Hills Patient Discount Program Application (2021) (Fillable) (PDF)
Patient Discount Program Income Chart (2021) (PDF)
MSP Questionnaire (Long Form) (Fillable) (PDF)
MSP Questionnaire (Short Form) (Fillable) (PDF)