For questions or more information please contact our Health Information Management Department (HIM) at 618-443-2177, ext. 3336.
Click the buttons below to download your Patient Forms
Parents – please complete this form before your athlete arrives at his/her Sports Physical.
The Patient’s Toolkit for Diagnosis can be picked up at your providers office. It is created for people who are not feeling well or visiting their doctor or nurse with a health concern. It has a set of prompts and questions to help you participate and partner with your medical care team – doctors, nurses, and other health care professionals and support staff.
This form is your consent to allow our facility to provide medical care to you, share your health information as described within, and received payment for services provided to you.
The Patient Intake form provides Sparta Community Hospital with important personal information about your health history and individual healthcare needs.
The Pediatric Patient form provides Sparta Community Hospital with important personal information about your child’s health history and individual healthcare needs.
This form allows you to give an authorized representative access to your personal health information through the patient portal.
This form is your request for access to your own health information via a patient portal account.
Complete this form to request Sparta Community Hospital to send your medical records to another person or organization.
Complete this form to request a Quality Health Care Clinic send your medical records to another person or organization.
Please complete and bring these forms to your Medicare Wellness Visit.
Please complete and bring these forms to your Weight Management Clinic visit.