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Medical Forms

Advance Directives, Medical Records & Medication Tracking

We have provided downloadable forms for your convenience. Complete the forms to request a copy of your medical record or direct medical care for yourself. To prepare for a health assessment and treatment, complete the medication tracking form. Forms are available in both English and Spanish.

Advance Healthcare Directive

You may be asked if you have a Durable Power of Attorney for Health Care, and Advance Healthcare Directive and/or a POLST.

An Advance Healthcare Directive (AHD) is a document allowing you to make a decision in advance of the need for the decision. It is designed to direct medical care for you if you are unable to do so. This is helpful for adults of all ages and is useful in situations where you cannot speak for yourself. Completing the AHD does not mean you do not want treatment. It is designed to give specific direction to your physicians and your family.

An Advance Healthcare Directive can help put your mind at ease and enhance your doctor's and your family's knowledge regarding your wishes for medical treatment. An AHD can prevent treatment you would not choose for yourself and decrease feelings of helplessness or guilt for your family.

Advance Healthcare Directives often include instructions on:

  • Whether or not to continue life sustaining treatment
  • Any medical procedures you do not want performed for either personal or religious reasons
  • Whether to continue your care in the hospital, an assisted care facility, or with a trusted loved one
  • Who to contact in the event of an emergency
  • Whether or not your family or friends can be consulted regarding your care

Because it is almost impossible to plan for every contingency, many people designate a trusted friend or family member to act as point of contact for doctors if they are unable to communicate. This individual will be responsible for making important medical decisions on your behalf.

Creating Advance Directives can be challenging. You may want to talk with your doctor about what sort of information should be included in your instructions.

Power of Attorney

A power of attorney is a legal document giving someone else the right to make a decision for you.


A Physician Order for Life Sustaining Treatment is a doctor's order honoring the patient's end of life treatment preferences; to have or to limit treatment, even when transferred from one care setting to another. A POLST is most appropriate for seriously ill persons with life-limiting or terminal illness or advanced frailty characterized by significant weakness and extreme difficulty with personal care activities.

Medical Record Request during COVID-19 Restrictions

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As we continue to monitor updates regarding the state of current events surrounding COVID-19 and any potential risk to our patients and staff, HIM (Medical Records) has decided to temporarily close our Release of Information desk.

We understand that access to your medical information is important and essential; we will still be available to process your requests for release of information remotely.

Effective Monday, March 23, 2020, all patient release of information requests can be submitted by e-mail, fax or US Mail. We will do our due diligence to process your requests in a timely manner.

Once the Health Information Department has received your request, it can take up to 7 business days to process.. To request a copy of your medical record, please complete the “Authorization to Disclose Health Information” form below:

To submit your request and scanned copy of valid Identification


Fax: (559) 675-5519

US Mail: Attn: Health Information Management

1250 E. Almond
Madera, CA 93637

Medication Tracking