Patient Forms

This page provides helpful forms for your visit to Mt. Ascutney Hospital and Health Center (MAHHC). Please contact us if you have any questions.

Forms for medical record management

Consent for release of information form

Download and complete this form if you need to release your medical records to someone else. When complete, please return the form to the Health Information Management department at MAHHC. Please visit our Locations & Directions page for our mailing address. Read about medical records at MAHHC.

Request to designate a personal representative

You have the right to access your protected health information (PHI). You may choose a personal representative who will have the same rights to access your PHI as you do.

Completing this form allows our caregivers and staff to talk with your personal representative. You are allowing us to talk with your representative about your care without your specific consent or authorization. Your permission includes verbal communication and access to your written records. Your representative is also allowed to view records and request copies on your behalf.

Clinic registration forms

To register as a new patient at MAHHC, before your appointment, download and complete these time-saving forms. You may return the forms to MAHHC by mail, fax or in-person. The proper fax number and mailing address are at the bottom of each form.

Forms related to medical services

Consent to treat a minor in parent/guardian's absence

MAHHC can only provide non-emergency care to minors with parental or guardian consent. Complete and return this form to provide consent for a minor's appointment. Please include current contact information.

When completed, please fax the form to 802-674-7314 or mail it to Mt. Ascutney Physicians Practice. Please visit our Locations & Directions page for our mailing address.

Request for ethics consultation

If you have an ethical question or concern about medical care, the MAHHC Ethics Committee welcomes the opportunity to assist you. Complete this referral form to request a consultation. Mail the completed form to Jill Lord, Ethics Chair, in MAHHC Administration. Please visit our Locations & Directions page for our mailing address.

We will contact you to schedule a meeting with the appropriate people involved. Please call Jill Lord, Ethics Chair, at 802-674-7224 if you have any questions.

Confidential financial disclosure statement

If you are applying for financial assistance, please complete and return the Confidential Financial Disclosure Statement (PDF).

Printable medication card

Keep track of your current medications with our convenient medication card. Fill out and carry this card to share important information with dentists, doctors and other caregivers.