Lindner Center of HOPE (LCOH)

Consent to Treatment-LCOH

Online Form or Printable File

NOPP- Notice of Privacy Practice Handout

Printable File

HIPAA- Acknowledgement of Receipt of Notice of Privacy Practice

Online Form or Printable File

Financial Responsibility Agreement-Self-Pay-LCOH (based upon insurance)

Online Form or Printable File

Medicaid Waiver-LCOH (based upon insurance)

Online Form or Printable File

MDCR (ABN) Advance Beneficiary Notice (based upon insurance)

IOP Services

Online Form or Printable File

Consent to Treatment-LCOH

Online Form or Printable File

NOPP- Notice of Privacy Practice Handout

Printable File

HIPAA- Acknowledgement of Receipt of Notice of Privacy Practice

Online Form or Printable File

Verbal Release of Information

Printable File

Authorization to Release-Documents

Printable File

Financial Responsibility Agreement-Self-Pay-LCOH

Online Form or Printable File

Medicaid Waiver-LCOH

Online Form or Printable File

MDCR (ABN) Advance Beneficiary Notice

IOP Services

Online Form or Printable File

Behavioral Health (BH) Financial Responsibility Agreement

Online Form or Printable File

Financial Assistance Application

Printable File

(Spanish) Printable File

Financial Assistance Plain Language Summary Handout

Printable File

(Spanish) Printable File

Financial Assistance Policy

View Form

(Spanish) View Form

Collection & Bad Debt Policy-LCOH

View Form

(Spanish) View Form

If you need assistance, please call:

Hospital Main Line: 513-536-HOPE
Lobby Registration Direct Line: 513-536-0560

If you are not using the online form completion option, completed documents may be sent by

Mail to:
Lindner Center of HOPE Registration
4075 Old Western Row Rd.
Mason, OH 45040

Lobby Registration Fax Line: 513-536-0648 (fax-to-email line)
Registration Email: lcohregistration@lindnercenter.org