Patient Forms

Download Free Adobe Reader

Important Instructions for Fillable PDF Files: 

  • Fillable PDF forms will require the free Adobe Acrobat Reader software or smartphone app.
  • Please download the fillable PDF to your computer or device before filling out your information.
  • Once a form is filled out, please save your file before sending to OHHS. To save a PDF, choose File > Save or click the Save File icon  in the toolbar at the bottom of the PDF. 
  • When ready, click the "E-mail Form to OHHS" button. This will prompt you to select a default mail application, such as Outlook, or to use a Web mail service, such as Gmail. Please select the option that is configured on your device.
  • iPhone and smartphone users may need to "share" the PDf to open it in the Adobe Acrobat Reader app. Please be sure to download the free app before using the "share" feature.

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 (PDF)
Patient Contact Form (Fillable) (PDF)
Patient Rights and Responsibilities Statement (Fillable) (PDF)
Consent for Treatment and Payment Agreement (fillable) (PDF)
Authorization for Disclosure of Health Information (PDF)
OHHS Sliding Scale Application (2020) (Fillable) (PDF)
Sliding Fee Scale Income Chart (2020) (fillable) (PDF)
MSP Questionnaire (Long Form) (PDF)
MSP Questionnaire (Short Form) (PDF)