Patient Forms
The following forms are provided to help streamline the process for registering. Please print the forms for the department area that you will be receiving services and bring them with you on the day of your evaluation.
If you are receiving Tele-Health or Tele-Therapy services, the Consent for Tele-Health Services has been provided as a fillable PDF. Please download the form, fill it out on your computer, save and email the form to ACSSupervisors@helenhayeshosp.org
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+ Tele-Health Forms
These forms are for patients receiving Physician Tele-Health Clinic or Tele-Therapy services.
- Consent for Tele-Health Services – Please fill out and email to ACSSupervisors@helenhayeshosp.org
- Tele-Health FAQs
+ Outpatient Therapy Forms
Please print, fill out, and bring to your evaluation
- Ambulatory Care Consent for Treatment
- Authorization to Access Patient Information through a Health Information Exchange Organization
- Authorization to Access Patient Information through a Health Information Exchange Organization – Spanish
- Disclosure Statement and Acknowledgement of Financial Responsibility
- Driving Program Packet
- Driving Program Referral
- Missed Appointment Policy
- Outpatient Therapy Health Questionnaire
+ Bone Density
Please print, fill out, and bring to your evaluation
- Ambulatory Care Consent for Treatment
- Authorization to Access Patient Information through a Health Information Exchange Organization
- Authorization to Access Patient Information through a Health Information Exchange Organization – Spanish
- Disclosure Statement and Acknowledgement of Financial Responsibility
- Bone Health Questionnaire – First Visit
- Bone Health Questionnaire – Return Visit
+ Cardiac Rehabilitation
Please print, fill out, and bring to your evaluation
- Cardiac Rehabilitation General Guidelines
- Outpatient Cardiac Rehabilitation Discharge Policy
- Authorization to Access Patient Information through a Health Information Exchange Organization
- Authorization to Access Patient Information through a Health Information Exchange Organization – Spanish
- Disclosure Statement and Acknowledgement of Financial Responsibility
- Health Profile SF-12
- Informed Consent for Exercise Treatment
- International Physical Activity Questionnaire
- Patient Health Questionnaire-9 (PHQ-9)
- Rate Your Plate
+ Medical Doctors/Clinic
Please fill out and email to ACSSupervisors@helenhayeshosp.org
- Ambulatory Care Consent for Treatment
- Authorization to Access Patient Information through a Health Information Exchange Organization
- Authorization to Access Patient Information through a Health Information Exchange Organization – Spanish
- Disclosure Statement and Acknowledgement of Financial Responsibility
+ Pulmonary Rehabilitation
Please print, fill out, and bring to your evaluation
- Pulmonary Rehabilitation General Guidelines
- Outpatient Pulmonary Rehabilitation Discharge Policy
- Pulmonary Rehabilitation Participant Questionnaire
- COPD Assessment Test (CAT)
- Informed Consent for Exercise Treatment
- International Physical Activity Questionnaire
- Modified Medical Research Council Scale (mMRC)
- Patient Health Questionnaire-9 (PHQ-9)
