90 East Second StreetFQHC logo
P.O. Box 270
Emporium, PA  15834
Phone: 814-486-1115
Fax: 814-486-0404

Patient Forms and Information

Below you will find patient forms that you can print and complete prior to coming to one of our offices. There are also some informational documents for you to read located toward the bottom of this page.

NOTE: You will need to have Acrobat logo Adobe Reader installed in order to download forms & documents.

Cameron County Health Care Center Forms

• Cancellation No Show Policy
• HIPPA Consent
• Payment Collection Policy
• Privacy Practices
• Notice to Patients
• Patient Information Sheet

Cameron County Dental Center Forms

• Dental Health History
• Payment Collection Policy
• Notice to Patients
• HIPPA Consent
• Privacy Practices
• Patient Information Sheet

Mountain Top Area Medical Center Forms

• Cancellation No Show Policy
• HIPPA Consent
• Payment Collection Policy
• Privacy Practices
• Notice to Patients
• Patient Information Sheet

Johnsonburg Dental Center Forms

• Dental Health History
• Payment Collection Policy
• Notice to Patients
• HIPPA Consent
• Privacy Practices
• Patient Information Sheet

Fox Township Medical Center Forms

• Cancellation No Show Policy
• HIPPA Consent
• Payment Collection Policy
• Privacy Practices
• Notice to Patients
• Patient Information Sheet

Fox Township Dental Center Forms

• Dental Health History
• Payment Collection Policy
• Notice to Patients
• HIPPA Consent
• Privacy Practices
• Patient Information Sheet

Ridgway Medical Center Forms

• Cancellation No Show Policy
• HIPPA Consent
• Payment Collection Policy
• Privacy Practices
• Notice to Patients
• Patient Information Sheet

Kane Dental Center Forms

• Dental Health History
• Payment Collection Policy
• Notice to Patients
• HIPPA Consent
• Privacy Practices
• Patient Information Sheet

Informational Publications

• Cameron County Diabetes booklet
• Type 2 Diabetes Screening Fact Sheet
• Dental Clinic Tips for Parents
• Pennsylvania’s School Immunization Requirements

Accepted Payment Types

Accepted payment types

About Us

The Keystone Rural Health Consortia, Inc. began operations on February 2, 1976, in Emporium, PA and is under the direction of the KRHC Board of Directors and CEO, Kristie Bennardi.

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Contact

Phone: 814-486-1115
Fax: 814-486-0404

90 East Second Street
P.O. Box 270
Emporium, PA 15834