Click below on each form for the following:
Authorization for Release of Verbal Protected Health Information (PHI)
This authorization pertains to the verbal release of Protected Health Information (PHI).
- Authorization of Release of Verbal Protected Health Information Form English (PDF)
- Authorization of Release of Verbal Protected Health Information Form Spanish (PDF)
Authorization For Release of Health Information - Medical Records
This form identifies to whom we can release medical records and what records you want us to release.
- Authorization For Release of Health Information Form English (PDF)
- Authorization For Release of Health Information Form Spanish (PDF)
Authorization To Request Health Information From Outside Provider/Facility
This form identifies to whom we can request records from outside provider/facility.
- Authorization To Request Health Information From Outside Provider/Facility Form English (PDF)
- Authorization To Request Health Information From Outside Provider/Facility Form Spanish (PDF)
Consent for Minors
This form provides consent for treatment of minors with permission by the parent and/or legal guardian.
Daycare Physical Forms
This form is approved by the Kansas Department for Health and Environment and is required for all children in child care facilities. Please print and fill out patient portion prior to appointment. Click below for each form>>
Financial Assistance
We know that financial concerns can add to the stress of any medical need. This information is supplied to assist you in settling your accounts. We want you to concentrate on healing, not worrying about paying for medical care.
Financial Assistance Program Information is available at: http://www.ccmcks.org/financialassistance.php
Health Questionnaire Form
This is a questionnaire about your health and any family history of illness. It also covers immunizations, allergies and current medications.
HIPPA Policy (PDF)
This is Notice of Privacy Practice for Clay Center Family Physicians. We are committed to protecting the confidentiality of our records containing information about you.
Mental Health Client Intake Form
Thank you for your interest in being a client of Family Physicians. This form is used to collect information about new clients and for internal purposes only. The information you provide is confidential and will be treated accordingly.
Patient Registration Form
This form covers general patient information such as Name, Date of Birth, Address, Employment, Insurance, Emergency Contact and Responsible Party.
Sports Physical Forms - Kansas State High School Activities Association
This is the current, KSHSAA approved sport physical form. Please print this and complete patient portion before appointment.
Student Health Assessment Forms
Click below for each form>>