Forms Library

CTO Financial Hardship Cash Out Guidelines

Financial Hardship Cash-Out Guidelines

NMC ED Registration, RMC ED Registration, Outpatient Registration, SpineCare, Pre/Post, Wound Care & Diabetes Clinic Registration, Financial Clearance, Patient Access

CTO Cash Out Request Form

DCH Regional/Northport Medical Center Payroll Department CTO Cash Out Request Form

NMC ED Registration, RMC ED Registration, Outpatient Registration, Pre/Post, Wound Care & Diabetes Clinic Registration, Financial Clearance, SpineCare, Patient Access

Newborn Medicaid Name Update/Confirmation Form

Use this form to document the newborn's initial legal name after birth as it will appear on the Birth Certificate/Birth Worksheet. DCH Health System will use this information to update the newborn's hospital record and submit the newborn's information to Medicaid.

Financial Clearance

Newborn Medicaid Name Update/Confirmation Form

Financial Counseling

Patient Accounts Daily Cash Summary

This form is used to complete the end-of-day cash drawer reconciliation process. Staff use it to document the drawer number, date, department, cashier, computed close total from Salucro, petty cash/change fund total, cash over or short amounts, itemized cash totals, number of checks, check total, credit card total, and total deposit amount. The completed form must be turned in with credit card receipts, cash, checks, and the drawer detail and summary. The original copy goes with the deposit, and the duplicate copy stays with the department.

All Departments

Appointment of Representative

This form is used when a Medicare beneficiary, provider, or supplier wants to appoint another person to act as their representative for a Medicare claim, appeal, grievance, complaint, or request. The form allows the representative to receive information, submit requests, present evidence, and act on behalf of the patient or party. The representative must accept the appointment by completing and signing the form.

All Departments

Notice of Privacy Practices

This form explains how a patient’s medical information may be used and shared, as well as the patient’s rights regarding their health information. It outlines the patient’s rights to access records, request corrections, request confidential communication, limit certain uses or disclosures, receive a copy of the notice, choose someone to act on their behalf, and file a complaint if they believe their privacy rights have been violated. It also explains how DCH may use or disclose health information for treatment, payment, health care operations, public health and safety, legal requirements, workers’ compensation, health information exchange, and other permitted purposes.

All Departments

Appointment of Representative - Spanish

This form is used when a Medicare beneficiary wants to appoint another person to act as their representative for a Medicare claim, appeal, complaint, or request. The Spanish version allows the patient to authorize a representative to receive information, submit requests, and act on their behalf. The representative must also accept the appointment by completing and signing the form.

Patient Access

Notice of Non-Coverage

This form is used when a patient’s insurance may not cover a specific procedure, service, or item. It lists the CPT code or procedure name, the reason insurance may not pay, and the estimated cost. The form allows the patient to make an informed decision about whether they want to receive the service, whether they want insurance billed, or whether they do not want to receive the service at that time. By signing, the patient acknowledges that they understand they may be financially responsible if insurance does not pay.

Patient Access