January 16, 2018

Clinic Patient Forms

To serve you in a more timely manner, please select the appropriate form(s) from the list below, print out, complete and mail back to the office you are seen in prior to your appointment. If you have questions regarding which forms are necessary for your visit, please contact our office at 913-894-8500.

  1. Patient Medical History
  2. Patient Information
  3. Patient Authorization for Disclosure/Release of Medical Information
  4. Consent to Test for HIV Antibodies
  5. Bladder Diary and Urinary Evaluation
  6. Release of Medical Records to Outside Facility or Patient
  7. Release of Medical Records from Outside Facility to KCWC
  8. Patient Rights and Responsibilities
  9. HIPAA Notice of Privacy Practices