St. James Mercy Hospital, Hornell NY
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  Patient Forms
St. James Mercy Hospital


Forms

  1. Universal Medication Form and Instruction Sheet (PDF)

    It is important to have a listing of the medications that you are currently taking with you at all times in case of an emergency. Please download and print the Universal Medication Form and document all of the medications that you are currently taking and update on a regular basis. Doctors also need to know herbals, vitamins and over-the-counter medications that you are taking. This will help you as a patient by your doctor knowing what concerns may be found and prevented by knowing what medications that you are currently taking.


  2. Authorization for Release of Health Information, HIPAA (PDF)


  3. New York State Health Care Proxy Form (PDF)


  4. Notice of Privacy Practices in English (PDF)


  5. Notice of Privacy Practices in Spanish (PDF)


 
 

St. James Mercy Hospital
411 Canisteo Street
Hornell, NY 14843
(607) 324-8000
information@sjmh.org
www.stjamesmercy.org

 
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St. James Mercy Hospital is located in Hornell, NY, and serves Steuben Co. and the surrounding region.

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