Forms

Request of Information Form (ROI)

If you have a Heart of America Medical Center MyHealth login and are requesting records for yourself, you can request records through your MyHealth account.  Log in, go to the Messaging tab then click on Non-urgent medical advice then go to General Question and follow the instructions. Within the message box describe which records you would like released and where the records are to be sent.
 
For all other requests, download and print the Release of Information form below.

Complete the Release of Information form in its entirety.

Sign and date the form. If you need help completing the form, please contact our Medical Records office at the number or email provided.  

Once completed, submit the form to the Medical Records office to the address below or requests can be made by email, mail or fax. There may be a charge for copies of your medical records. If there is, we will notify you before copies are made. Once we receive your payment, your request will be processed.

Heart of America Medical Center
Health Information Services
800 South Main Ave.
Rugby, ND 58368
Ph: 701-776-5455 ext. 2257
Fax: 701-776-5448
hamcroi@hamc.com



Release of Information Form (Fillable)
 

Current Medication List

It is imperative that your medical provider and nursing staff have knowledge of your allergies, immunizations and current medications, including over-the-counter, vitamins and herbal medications. Please bring all the medications you take at home to the hospital with you, or bring a current list of medications. You can download a form below that includes all this information. Please keep this form with you at all times and update it as changes occur.

Download the Medication Listing Form
 

Advanced Directive

An advance health care directive communicates your health care decisions should you be unable to make or communicate them for yourself. For more information, please see the Advanced Care Directive section of this website or download a form below.

Download the Advanced Directives Form
 

Community Care Program

Heart of America Medical Center's Community Care Program is available to individuals who cannot afford to pay their medical bills and who meet financial guidelines. For more information, please see the Community Care section of this website or download an application form below.

Notice of Availability of Community Cares March 2016

Residents' Rights

Our goal is to treat our residents with the utmost care and respect. However, should you have questions or concerns about your care, privacy, fees and services we encourage you to consult our Resident's Rights manual. A PDF of the document can be downloaded below.

Download the Residents Rights Form
 

Grievance Procedure

At Heart of America Medical Center, we strive for excellent care. If, for some reason, you feel this has not been the case, please bring this concern to any staff member and/or supervisor of the department for which the issue pertains. If you are still not satisfied with the outcome, you may refer to our Grievance Procedure. A PDF of the procedure can be downloaded below.

Download Grievance Step by Step Form

Ethical Issues

If you or a member of your family is facing a difficult medical decision, the Ethics Committee at Heart of America Medical Center may be able to help you. Please also consult your medical provider, nursing staff, hospital chaplain and social services as much as necessary for support, education and consultation. If you still feel you need the assistance of the Ethics Committee, the Ethical Issue Form may be downloaded below. Please follow the instructions on the form for submission.

Download the Ethical Issues Form
MyHealth Portal