Click below on each form for the following:
Authorization for Release of Verbal Protected Health Information (PDF)
This authorization pertains to the verbal release of Protected Health Information.
Consent for Minors (PDF)
This form provides consent for treatment of minors with permission by the parent and/or legal guardian.
Daycare Physical (PDF) | Daycare Physical Spanish (PDF)
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.
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
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.
Health Questionnaire Form (PDF)
This is a questionnaire about your health and any family history of illness. It also covers immunizations, allergies and current medications.
Patient Registration Form (PDF)
This form covers general patient information such as Name, Date of Birth, Address, Employment, Insurance, Emergency Contact and Responsible Party.
Request For Medical Records (PDF)
Authorization For Release of Health Information (PDF)
This form identifies to whom we can release records and what records you want us to release.
Sport Physical Form (PDF)
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>>