Clergy Visitor Form

If you are clergy or authorized hospital care ministers and would like to request to be added to the list of Clergy approved to visit patients complete this form:
Clergy Name*
Cell Phone*
Email*
Church Name*
Address*
City, State, Zip*
Church Phone*
Federal Patient Confidentiality Regulations (HIPAA)
I understand that medical information about a hospital patient is private, including the fact that a patient is hospitalized. I hereby agree to keep such information confidential unless the patient or an authorized family member has given me explicit permission to relay the information to others. I understand that I may visit only with members of my organization.
Signature*
Date*
MM slash DD slash YYYY
Upload or bring with you on your first visit to McLeod, documentation that can verify your Clergy Status:
- Business card
- Church Bulletin with your name on it
- Authorization letter
Upload Documentation
Accepted file types: jpg, pdf, png, jpeg, doc, docx, Max. file size: 25 MB.

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