Many commonly requested forms are available for download from this site. 

If you do not see a form you are looking for please call us and we will be happy to help you.

Brochures

• Patient Safety Information - Help us Help You
• Understanding Your Bill
• Mental Health Advanced Directives - Understanding
• Patient Rights & Responsibilities
• Death with Dignity - Notice of Non-Participation
• Death with Dignity Informational Brochure

Forms

• Application for Financial Assistance

• Request for Medical Records

• Advanced Admission Registration Form

• Medicare Advanced Beneficiary Notice (ABN) Form

• Blood Transfusion Consent Form

• General Medical  Consent Form

• Medication Self Administration Assessment Form

• Pain Management Agreement

• Pain Agreement Referral Consent Form

• Physician Orders for Life Sustaining Treatment (POLST) Form

• Psychotropic Medication Informed Consent

• Psychotropic Medication Risk and Benefit Information

• Tobacco Quit Line Referral Form

• Universal Quality Safety Compliance Incident Report Form

• Patient Name Change Request Form

Contact Information

Telephone

509-843-1591

FAX

509-843-1234

Postal address

66 North Sixth Street, Pomeroy, WA 99347

Electronic mail

General Information: info@GarfieldCountyPHD.org
Webmaster: ceo@GarfieldCountyPHD.org