Citizens Medical Center
Family Center for Health Care
Prairie Senior
Citizens Foundation

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.

Citizens Medical Center

Advanced Directives

Authorization for Release of Health Information

DNR – Do Not Resuscitate Directive

Health Expo Registration Form

Laboratory Direct Access Form

Medical Records Request Form – Incoming

Medical Records Request Form – Outgoing

Medical Records Request Form Incoming – Español

Medical Records Request Form Outgoing – Español

Financial Assistance Application – English

Financial Assistance Application – Español

Family Center for Health Care

Workers Compensation Authorization Form

Pre-Participation Physical Evaluation

Instrucciones Para El Examen Fisico Previo A La Participacion

Payment Arrangement Agreement

Notice of Privacy Practices

Patient Registration Form

Injury Form

NPP Acknowledgement and Release of Info

Health History Questionnaire

Helpful Information

Medically Assisted Nutrition

Life-Sustaining Treatments

Choosing an Agent