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

Patient Confidentiality Form

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

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 questionnaire and booklet explains your rights in detail and gives you the opportunity to fill out the information needed for such medical decisions to be made.

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.


In addition you will receive pamphlets on the following:

Patient Rights and Patient Concern Policy Brochure

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

Message from Medicare (For Medicare patients)

Medicare has information concerning the rights of Medicare patients. It explains your right as a Medicare Hospital Patient.

After Your Stay

Electra Memorial Hospital has partnered with HealthStream Research™ to conduct patient satisfaction surveys. Following your stay with us you may receive a call from HealthStream Research™. This call will only take a few minutes and your feedback will be used by Electra Memorial Hospital to continually provide excellent patient care. Patients are randomly selected so please complete the survey if you are chosen. If you have any questions about the survey process or your stay with us, please contact Kim Gilbert, Chief Nursing Officer, at 940-495-3981.