Resources (Planet Heart)

PATIENT FORMS

• Charity Care – Financial Assistance 10.19

• Consent to Release of Financial Information  (English)

• Consent to Release of Info  (English) (Spanish)

• Financial Assistance Application  (English) (Spanish)

• Financial Assistance Policy  (English) (Spanish)

• Financial Assistance Summary  (Spanish) (English)

• Financial Policies Brochure

• Living Will Durable Power of Attorney Form

• LRH Chargemaster List

• LRH Foundation College Scholarship Application 2024

• LRH Foundation High School Scholarship Application 2024

• Notice of Privacy Practices

• Patient and Family Engagement Application

• Patient Rights and Responsibilities  (English) (Spanish)

• Policy – Collection of Accounts

• Release of Medical Records Information  (English) (Spanish)

• SHIIP Client Information Form 2020

• SHIIP Medicare Comparison Sheet

• SHIIP Prescription Drug List 2020

• Consent to Release of Medical Information Form  (English) (Spanish)