Patient Forms & Resources
DEPARTMENT OF HEALTH & HUMAN SERVICES
Public Health Service
Oklahoma City Area
Kansas Service Unit
Haskell Indian Health Center
In an effort to exceed the needs of our patients we are now making registration forms more readily available. This will enable patients to establish eligibility or update their information through the mail upon a patient’s request. Upon doing so, please note the following:
- Patient’s eligibility for services must be proven and accepted. If a patient does not provide adequate proof of eligibility, a chart will not be established until such proof is provided. It is the responsibility of these individuals to provide the necessary eligibility information to receive ongoing services.
- All patients must be registered in the Patient Registration system before an appointment will be created or care is rendered, with the exception of emergency services. On subsequent encounters, each patient’s demographic and third-party (insurance) information must be updated.
The forms required for new chart processing may be provided upon request through the mail, email, or use the PDF link on this webpage to print and complete at home.
For New Patients:
Please complete the following forms found in the PDF link below:
- New Chart Application
- Receipt of Privacy Practices
- Assignment of Benefits (and be prepared to present insurance card)
- Advance Directive Policy Confirmation (Do you have an active Living Will?)
Once all information necessary to complete the chart are appropriately obtained, you will receive a call confirming the completion of your chart including your new chart number within our system and the documentation that is needed to finalize your new chart once you arrive in person. At this point you can schedule an appointment for services.
You are also welcome to come in at any time to create your new chart. If you have additional questions please call (785) 843-3750 option 0.
Thank you for choosing Haskell Indian Health Center for your health care needs!
Adult Patient Registration Packet
Student and Pediatric Patient Registration Packet
Pediatric Patient Consent Letter
Patient Welcome Packet
Advanced Directive Information
