Patient Forms
  • Your Privacy
    This Privacy Notice describes how we may use and disclose your protected health information to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your right to access and control your protected health information. Your "protected health information" means any written or oral information about you, including demographic data that can be used to identify you, created or received by your health care provider, which relates to your past, present, or future physical or mental health or condition. Click here to download the Privacy Notice Document (HIPAA).

  • Your Rights and Responsibilities
    This document (a) provides you with your Rights and Responsibilities relating to your surgery, (b) describes how to file a grievance, if desired, (c) provides information concerning physician ownership of our hospital and (d) sets forth our hospital's policy with respect to advance directives. Click here to download the Patient Rights & Responsibilities Form.

  • JCAHO Accreditation Public Notice
    The Joint Commission is an independent, not-for-profit, national body that oversees the safety and quality of health care and other services provided in accredited organizations. Information about accredited organizations may be provided directly to the Joint Commission at 1-800-994-6610. Information regarding accreditation and the accreditation performance of individual organizations can be obtained through the Joint Commission's Web site.

The Joint Commission may conduct an unannounced accreditation survey of Memorial Hermann Surgical Hospital Kingwood at any time. Click here to download the JCAHO Public Notice.

Other Forms (click to download) Safety or Quality of Care Concerns

Any Patient, Family Member, Visitor, Advocate, or Employee who has concerns about the Safety or Quality of Care provided in this organization, that have not been adequately addressed by the management of this organization, may report their concerns to the Joint Commission or the Texas Department of Health. There will not be any blame or action(s) taken against a person or a group who chooses to inform JCAHO or TDSHS of concerns about the Safety or Quality of Care provided in this organization. The contact numbers are listed below.

The Joint Commission

Fax: Office of Quality Monitoring, (630) 792-5636
Mail: Office of Quality Monitoring
The Joint Commission
One Renaissance Blvd.
Oakbrook Terrace, IL, 60181

Texas Department of State Health Services

Phone: (888) 973-0022
Mail: Patient Quality Care Unit
Department of State Health Services
1100 West 49th Street
Austin, TX 78756-3199

Memorial Hermann Surgical Hospital Kingwood is a hospital in which physicians have an ownership or investment interest. The list of physician owners or investors is available to you upon request.