(316) 263-5891
(800) 234 4565 ** FAX (316) 263-3083

FORMS

At Wichita Nephrology Group, we value your time. As with any first visit, there is paperwork to fill out. Please feel free to fill out the following forms at your leisure and present them at your first visit. Medicare patients, please take note of the 2 additional forms.  If you have any questions, please contact us!

So that we may file your insurance, please fill out the following forms and bring them to your first visit. If you have Power of Attorney or Conservatorship, please return a copy of the legal document so it can be placed on the chart. Please have your insurance card with you as well.

PATIENT FORMS

New Patient PDF
Map/Parking PDF
Patient Registration PDF
Permission & Privacy PDF
History & Physical PDF
Authorization For Disclosure Of Protected Health Information
Acknowledgement Of Receipt Of Notice Of Privacy Practices
Patients Rights and Responsibilities
Ownership Declaration
PATIENT_FINANCIAL_POLICY

MEDICARE FORMS - These are to be filled out in addition to the above forms.

Secondary Payer Questionnaire PDF
One Time Authorization PDF

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