Please print the form, fill it out completely, and then return via either fax or mail to the number/address at the bottom of the form.
Consent for release of information (ROI)
Consent to treat a minor in parent/guardian's absence
MAHHC cannot provide non-emergency care to minors without proper parental or guardian consent. It is important that you complete this form in its entirety and note any contact numbers where you can be reached at the time of the visit should the providers need to speak with you.
When completed, please mail to Mt. Ascutney Physicians Practice, 289 County Road, Windsor, VT 05089 or fax to (802) 674-7314.
Confidential financial disclosure statement
If you are applying for financial assistance, please complete the Confidential Financial Disclosure Statement (PDF).
Ethics consult request
All ethical concerns are welcomed by the Ethics Committee. Please send this referral form to Ethics Chair, Jill Lord, in MAHHC Administration.
Once a referral is received, you will be contacted so that a meeting can be scheduled with the appropriate people involved.
The Ethics Committee policy outlines the referral process. If you have any questions regarding the need for an Ethics Committee Consult, feel free to contact the Ethics Chair (Jill Lord, x-7224).
Request to designate a personal representative
A personal representative has the same rights of access to your protected health information as you do.
MAHHC, the Mt. Ascutney Physician’s Practices, and Ottauquechee Health Center will be allowed to provide information to the person you designate without your specific consent or authorization. This includes verbal communication and access to your written records, including being allowed to inspect the record and request copies on your behalf.
Printable medication card
Print and carry this card with you at all times. The information is essential to anyone who provides you with dental, medical, surgical, or emergency care.