Patient Forms

If you have a Heart of America Medical Center MyChart login and are requesting records for yourself, you can request records through your MyChart 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 you've completed the form, submit it to Medical Records office at the address below. Requests may also 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.

Download the Release of Information Form Here:

The Release of Information Form may also be found within your MyChart.

To Direct a Question to HAMC Health Information Services Click Here:

Heart of America Medical Center

Health Information Services

800 South Main Ave.

Rugby, ND 58368

Ph: 701-776-5455 ext. 2224

Fax: 701-776-5448

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Current Medication List

Your medical provider and nursing staff must know about 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 will help you document your medications and vitamins. Please keep this form with you at all times and update it as changes occur.

Download the Current Medication Form Here:

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Advance Directive Form

An advance health care directive communicates your health care decisions should you be unable to make or communicate them for yourself. Our social services staff is prepared to provide support and information to help you create a legal advance health care directive.

In your advance health care directive, you will appoint a health care agent. Without the directive, state law determines who will make decisions on your behalf if you are unable to do so.

Copies of the Advance Health Care Planning Resource Guide for North Dakotans are available through our Social Services Department.

HAMC Social Services Contact:

Shannon Amyotte, LBSW

Director of Social Services

(701) 776-5455 ext. 2145

Click HERE to send a message to our Social Services Director.

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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 the required financial guidelines. For more information, please see the Community Care section of this website or download an application form below. Income guidelines can be reviewed below:

Financial Income Guidelines

Community Care Policy

Community Care Policy (Plain Language)

Community Care Application

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Resident's 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.

Download the Resident's Rights Document Here:

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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, the nursing staff, the hospital chaplain, or social services 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.

View the Ethical Issues Form Here:

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Patient Grievance Reporting

At the Heart of America Medical Center, we strive to provide excellent care. If you feel this has not been the case, please bring your concern to any staff member and/or supervisor of the department. After this, if you are still not satisfied with the outcome you may refer to our grievance procedure policy.

Good Samaritan Hospital Association (GSHA) does not discriminate, exclude, or treat people differently on the basis of race, color, national origin, sex, age, or disability in its health program and activities. If you believe that GSHA has failed to provide services or discriminated in another way please follow the steps below.:

• Talk the issue over with the department director or nurse in charge.
• Report the issue via voicemail to our Compliance Department 1-855-252-7606.
• Submit an event through the Compliance Hotline.

Any reports may be completed by telephone or online anonymously.

German

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verügung. Rufnummer: 1-855-293-8133 (TDD 1-701-776-5043).

Spanish

ATENCIÓN: si hablas español, hay servicios gratuitos de asistencia lingüística disponibles. Llame al 1-855-293-8133 (TDD 1-701-776-5043).

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The Good Samaritan Health Services Foundation has a fund to help cancer patients who are financially eligible with financial assistance. You can download the application form here. After filling out the form, you may submit it to the GSHS Foundation Director via email at mmckay@hamc.com, or by dropping it off at the hospital admissions desk.

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