Patient Rights Templates

This form is used for making a request to restrict the use or disclosure of your personal health information under the HIPAA privacy laws in the state of Wisconsin.

This form is used for filing complaints against providers and partners of the Oregon Health Plan.

This form is used for giving authorization to someone to obtain your health information in the state of New Mexico.

This form is used for applying for initial certification for Behavioral Health Services in Wisconsin. It includes information on patient rights and how to address patient grievances.

This document allows individuals in Idaho to request a change in their primary physician.

This form is used for filing consumer complaints regarding prescription hearing aids in Pennsylvania.

This document outlines the code of ethics that resident hospice workers in Maine must adhere to. It sets guidelines for their professional conduct and responsibility.

This document is used for obtaining legally required consent from individuals in Alpine County, California. It ensures that individuals are fully informed and understand the risks and benefits associated with a particular activity or procedure.

This document is used for authorizing the release of medical information under the Health Insurance Portability and Accountability Act (HIPAA) in New York.

This document is used to indicate the refusal of medical care in the state of Illinois. It allows individuals to decline certain treatments or procedures for themselves.

This document allows individuals in Arkansas to express their medical treatment preferences in end-of-life situations. It helps healthcare providers understand the patient's wishes for life-saving measures, resuscitation, and other treatments.

This form is used for nursing facilities in Texas to disclose information about their memory care services for residents. It provides details about the facility's specialized care programs and staff qualifications.

This form is used for disclosing important information about memory care services in Texas assisted living facilities.

This form is used for requesting action in long term care in the state of Alabama.

This document is used to appeal a Utilization Review (UR) determination in the state of Delaware.

This form is used for recertifying behavioral health services. It is specifically for DHS 94 patients to exercise their rights and resolve grievances, as well as for maintaining the confidentiality of treatment records in Wisconsin.

This document is a provider access agreement for a managed care organization in the state of Utah. It outlines the terms and conditions for healthcare providers to participate in the organization's network.

This document outlines the procedures related to the protection of patient health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA) in the state of Minnesota. It helps patients understand how their medical data can be used and disclosed, and how they can gain access to this information.

This form is used by patients in New Hampshire seeking authorization for the therapeutic use of cannabis under the guidance of a guardian. The document outlines the patient's diagnosis, proposed treatment and guardian's information.

This document is for the Illinois residents and is used to request and guide medical practitioners on life-sustaining treatment decisions. It is available in English and Chinese languages.

This document is a legal agreement that outlines the process of resolving disputes between a physician and a patient through arbitration instead of going to court.

This document is a Sample Treatment Agreement. It is used by healthcare professionals and patients to outline the terms and conditions of treatment, including payment, confidentiality, and responsibilities of both parties.

This document is typically utilized by health care providers to justify the medical needs and treatments of a patient for insurance coverage purposes. It contains specific details regarding the patient's condition and the recommended treatment or medical services required.

This type of document is used in Vermont and is available in English and Vietnamese. It is an Advance Directive short form, which allows individuals to specify their medical preferences and appoint a healthcare agent in case they are unable to communicate their wishes.

This form is used for reporting patient choice at the end of life by physicians in Vermont.

This form is used for obtaining consent for seating and positioning services in the state of Tennessee.

This Form is used for designating an authorized representative to handle managed care appeals in Iowa.