Patient Forms

To download the following forms, please click on the name and a new window will open with the form as a pdf document. You will need Acrobat Reader to open and print the form.


Download Acrobat Reader here.


Authorization for the Release of Patient Protected Health Information

Lindner Center of HOPE Outpatient Forms

Lindner Center of HOPE Outpatient Acknowledgement of Patient Information

LCPA Outpatient Forms

Financial Assistance Application


Request for Access or Copy of Patient’s Medical Record


 Lindner Center of HOPE (LCOH) maintains an electronic medical record (EMR).

All information in the medical record will be confidential and only disclosed for purposes of treatment, payment and operations (as defined in HIPAA), pursuant to a proper written authorization by the patient or court order and appropriate regulatory agency compliance surveys.

A patient, or the patient’s legal representative, may request to review or obtain a copy of the patient’s Protected Health Information (PHI)/medical record upon written request and with reasonable notice.

Lindner Center of Hope (LCOH) form titled: “Authorization for the Release of Patient Protected Health Information” may be utilized as the written request. It is important that the form be completed, signed and dated by the patient or his legal representative. The release specifies what information may be released and to whom. It is valid for 6 months and it authorizes LCOH to release information for services already performed, not for services or treatment that occur in the future.

The patient is entitled to receive the first copy of their medical record at no charge.

Any request from a patient or the patient’s legal representative will be referred to his/her attending physician/primary therapist. Patients are permitted to review their own PHI, unless access is restricted for treatment reasons. The physician or therapist will document in the medical record the reason access is restricted.

Any requests for records may be directed to the Health Information Management Department at (513) 536-0205.

Authorization for the Release of Patient Protected Health Information Form