Forms

Advanced Directives

Dermatology

New Patients

Pediatrics

New Patient Registration

To save time on your first visit, print this form, fill it out, and bring it with you to your first appointment.

Download new Patient Registration

 Back to top

Pediatrics

During the course of childhood, your child will most likely need numerous forms completed by his/her pediatrician, whether for school, camp, sports and/or child care. Several of these forms are available for download. Save yourself -- and your pediatrician -- time by completing the necessary form(s) prior to your visit.

 Back to top  

Record Release Form

This document gives Group Health authorization for use or disclosure of patients’ protected health information. It allows you to select the type of information you allow to be released, as well as the reason for use and/or disclosure of your information.

To save time at your first visit, please print it, fill it out, and bring it with you to your appointment.

Download a printable Record Release Form

 Back to top   

Parent or Legal Guardian form

Download a printable Parent or Legal Guardian form

 Back to top

Dermatology form

Download a printable Dermatology form

 Back to top   

Advance Directives

An advance directive lets your doctor and others know your wishes concerning your medical treatment when you cannot speak for yourself. Some people may not want to spend months or years on life support. Others may want every step taken to lengthen life.

Group Health recognizes your right as a patient to make decisions about your care, including the right to accept or refuse treatment. We have policies in place to comply with your advance directive documents. Our staff will provide the same quality of care whether or not you have an advance directive. In all circumstances, our commitment is to your dignity and comfort.

Any person 18 years or older who is of sound mind and can make his/her own decisions can complete an advance directive. You do not need to complete an advance directive before you receive medical care.

There are several types of advance directives:

 Back to top

Health Care Power of Attorney

This document allows you to choose someone to make medical decisions on your behalf when you cannot speak for yourself. This could be for any period of time. It is important that you discuss your beliefs and values with the person you choose so he or she can follow your wishes. In regards to stopping life support, the Health Care Power of Attorney allows the person you name to stop life support only if you are in a coma from which you are not expected to recover or if you are expected to die within a short period of time.

If you do not have a Living Will or Health Care Power of Attorney, your physician/physicians may allow your next of kin to make certain decisions regarding your medical care if you are unable to speak for yourself. However, according to the law, any decision to discontinue life support may not be implemented right away without a Living Will or Health Care Power of Attorney. You may need to stay on life support for an extended length of time before it could be discontinued.

If you choose to complete a Living Will or Health Care Power of Attorney, you and/or your family should retain the original. Give copies to your doctor, to the hospital each time you are admitted and to trusted family members and/or friends. The person you have chosen to carry out your health care wishes should have a copy as well. For a fee, you may file a copy of your Living Will or Health Care Power of Attorney at your local county recorder's office. You may call them for more information.

Hamilton County: 513.946.4588
Butler County: 513.887.3192
Warren County: 513.925.1382

Your nurse can provide you with the forms at your request.

DNR Comfort Care and DNR Comfort Care Arrest were developed by the Ohio Department of Health to allow your physician to write a Do Not Resuscitate Order that will be honored after you leave the hospital. It is meant for those who are terminally ill or have serious medical conditions and have chosen not to have CPR (cardiopulmonary resuscitation) if their heart or breathing should stop. With a DNR Comfort Care order, emergency medical personnel will respond and will help make the patient comfortable but will not be required to perform CPR. To learn more about DNR Comfort Care and DNR Comfort Care Arrest, contact your physician. Once you have DNR Comfort Care status, you need to carry your identification card or ID bracelet with you at all times to verify the DNR order.

Only you can change or cancel your Advance Directives and you can do so at any time. Should you have any questions about completing the Living Will or Health Care Power of Attorney, contact Patient Relations at 513.865.1115. For legal advice, talk to your lawyer or contact Ohio Legal Services at 1.800.589.5888, Monday through Friday, 8:30 a.m. to 5 p.m.

Download a printable Health Care Power of Attorney form

Living Will

The Ohio Living Will includes an optional section in which you may state your preferences about organ and tissue donation. A Living Will informs your doctor in writing of your wishes regarding life support when you are too ill to speak. It also allows you to state whether you would want food and water artificially supplied or withheld.

Your Living Will takes effect only when:

  • You are in a coma from which you are not expected to recover,
  • You are beyond reasonable medical help with no hope of getting better and cannot make your wishes known or,
  • You are expected to die and cannot make your wishes known.

Two doctors must agree on your medical condition before the Living Will is acted upon. A Living Will is NOT the same as a Do Not Resuscitate Order that is written by a physician.

Download a printable Living Will form

Back to top