Patients

When you are admitted, you will be asked to fill out the following forms:

Medicare Secondary Payer Questionnaire (for Medicare patients)
This form is for Medicare patients. The questionnaire concerns patients with Black Lung (BL) Benefits and Medicare patients who are currently employed. This questionnaire helps Medicare identify Primary and Secondary payers so that your claims will be promptly processed for payment.

Advance Directive Acknowledgement and Advance Directives Booklet
Texas and Federal Laws require that patients be given the right to make their own healthcare choices, or the right to appoint someone to make those choices for them. This questionnaire and booklet explains your rights in detail and gives you the opportunity to fill out the information needed for such medical decisions to be made.

Patient Confidentiality Form
Patients have the right to privacy and security while staying in our hospital. By completing this form, you can make the decision to let your hospital stay be known to the public and visitors, or you can request that no information be released. By deciding that you do not want information released during your hospital stay, Electra Memorial Hospital will withhold your name from our patient census, hold your telephone calls, mail, and flowers.

In addition you will receive pamphlets on the following:

Patient Rights and Patient Concern Policy Brochure
As a patient of Electra Memorial Hospital, your rights as a patient are highly respected. Our admitting office will give you our brochure that will explain in detail your rights as a patient. We ask that you please read this or have a family member read it to you upon getting settled into your room.

Message from Medicare (For Medicare patients)
Medicare has information concerning the rights of Medicare patients. It explains your right as a Medicare Hospital Patient.

After Your Stay
When you are discharged from Electra Memorial Hospital, you will receive a questionnaire in the mail along with a stamped envelope. This is for your comments concerning your hospitalization, which allows us to address any needs or concerns that you may have.