Forms

Use this comprehensive list of Citizens Health forms to complete admissions, financial assistance applications and other aspects of your care. If you do not find the form you require, please call us at (785) 462-7511.

Advanced Directives

Directivas Avanzadas

Authorization for Release of Health Information

Autorización para la divulgación de información sanitaria

DNR – Do Not Resuscitate Directive

Grievance Form

Health Expo Registration Form

Laboratory Direct Access Form

Financial Assistance Application – English

Financial Assistance Application – Español

Workers Compensation Authorization Form

Authorization for Release of Health Information

Autorización para la divulgación de información sanitaria

Pre-Participation Physical Evaluation

Instrucciones Para El Examen Fisico Previo A La Participacion

Payment Arrangement Agreement

Notice of Privacy Practices

Injury Form

NPP Acknowledgement and Release of Info

Health History Questionnaire

Medically Assisted Nutrition

Life-Sustaining Treatments

Choosing an Agent