Notice to Patients Regarding Confidentiality

Patients have the right to privacy and security while staying in our hospital. Electra Memorial Hospital will withhold your name from our patient census and hold your telephone calls, mail, and flowers if you choose that you do not want information released during your hospital stay. By completing this form, you can decide to let your hospital stay be known to the public and visitors, or you can request that no information be released.

If your provider determines you need to be admitted to the hospital, you will be asked to fill out the following forms:

Message from Medicare (For Medicare patients)

If you are a Medicare patient, this explains information concerning your rights as a hospital patient.

Advance Directive Acknowledgement & Advance Directive Booklet

Texas and Federal Laws require that patients be given the right to make their own healthcare choices or the right to appoint someone to make those choices for them. This booklet explains your rights in detail and allows you to complete a questionnaire with the information needed for such medical decisions.

Medicare Secondary Payer Questionnaire (for Medicare patients)

This form is for Medicare patients. The questionnaire concerns patients with Black Lung (BL) Benefits and Medicare patients who are currently employed. This questionnaire helps Medicare identify Primary and Secondary payers so that your claims will be promptly processed for payment.

Patient Rights and Patient Concern Policy

At Electra Memorial Hospital, your rights as a patient are highly respected. Our admitting office will give you our brochure that will explain those rights. We ask that you please read this or have a family member read it to you upon settling into your room.

After Your Stay

Electra Memorial Hospital has partnered with Press Ganey to conduct patient satisfaction surveys. Following your stay with us, you will receive a survey from Press Ganey. This survey will take a few minutes to complete, and Electra Memorial Hospital will use your feedback to improve patient care. If you have questions about the survey process or your stay with us, please contact Kim Gilbert, Chief Clinical Officer, at 940-495-3981.


Jenny Kubicek, Director of Nursing

Phone: (940) 495-5247

Fax: (940) 495-3992