Patient Information

Patient Forms

For your convenience, we have provided downloadable PDF copies of our most commonly used forms:

Privacy Practices

Keeping patient information secure is a top priority for Rooks County Health Center. Our Privacy Notice (effective April 14, 2003) describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. 

To download a copy of our Privacy Notice, please click here.

If you have any questions about this Notice, our policies, or practices please contact:

Rooks County Health Center
Privacy Officer
P.O. Box 389
Plainville, KS 67663
785-434-4553

Statement of Patient Rights

The governing Board of Rooks County Health Center has established this statement in recognition of the hospital’s responsibility to adhere to patient’s rights and to recognize the patient’s responsibilities in the effort to offer the highest quality of care possible. Rooks County Health Center does not discriminate against patient with regard to age, sex, religion, race, ethnicity, national origin, mental or physical disability, sexual orientation, genetic information or source of payment.

Patient Rights:

  • Patients have the right to respectful and considerate care from all staff members at Rooks County Health Center.
  • Patients have the right to privacy and to have all communications, including medical records, treated with confidentiality.
  • Patients have the right to a safe and secure environment.
  • Patients have the right to a fair and efficient process for resolving differences with their health plans, health care providers and the Hospital.
  • Patients have the right to a choice of health care providers.
  • Patients have the right to access emergency health care services when and where the need arises.
  • Patients have the right to utilize advance directives.
  • Patients have the right to explanation for the need to be transferred.
  • Patients have the right to communicate with persons and services inside and outside the hospital.
  • Patients have the right to receive a copy and/or an explanation of their itemized total hospital bill.
  • Patients have the right to receive current, clear and complete information concerning their diagnosis, treatment, prognosis and to fully participate in all decisions related to their health care.
  • Patients, their family, or surrogate decision maker(s) have the right to make an informed consent for or refusal of a treatment and/or procedure.
  • Patients have the right to be free from restraints and seclusions.
  • Patients have the right to be free from verbal or physical abuse or harassment.
  • Patients who are unable to fully participate in treatment decisions have the right to be represented by parents, guardians, family members or legal representatives.
  • Patients have the right to refuse any experimental treatment affecting their care.
  • Patients have the right to transfer to another room.

Medical Records Center

The Medical Records Center is under the direction of the Health Information Management (HIM) department. The HIM department is responsible for overseeing the timely processing, completeness and retrieval of all patient medical records while maintaining patient privacy and confidentiality. The scope of services provided by the HIM department is based upon a collaboration and information sharing format to enhance patient care. HIM services are provided to all areas of the facility and all patients as appropriate to need and security levels.

HIM Services include provision of an accurate patient record, release of information and other services, with an emphasis on the following:
  • Correspondence
  • Compilation of Statistics
    Record Assembly and Analysis
  • Transcription
  • Coding and Abstracting
  • Record Retrieval, Filing and Storage 
    • Accessibility of the medical record is available at all times to those authorized persons requesting their use for patient care. All other requests can be made to the HIM Department during regular business hours. An Authorization for Release of Information form signed by the patient must accompany some requests.
    • Patients may also request a copy of their medical record by submitting a Request to Copy or Inspect form to the HIM department. RCH’s HIM staff complies with federal and state regulations to ensure every patient’s privacy while ensuring records are used and disclosed according to their purpose.
    • Records are filed and stored in secure locations both onsite and offsite. Access to stored records is restricted to staff members of the HIM department.
  • HIPAA Privacy and Security
    • The Health Insurance Portability and Accountability Act (HIPAA) went into effect on April 14, 2003. This law affects all aspects of healthcare. The employees at Rooks County Health Center are trained upon employment, as well as annually, regarding their responsibilities in relation to patient’s privacy.
    • Information obtained through a patient’s care is treated as confidential. Staff members, physicians, volunteers and business associates of Rooks County Health Center who have access to information concerning patients must hold all information in strict confidence.
    • Perhaps one of the most important aspects of the HIPAA rule relates to the release of health information, including information related to treatment and payment. When disclosing protected health information, a signed authorization is required except for those disclosures made for treatment, payment or healthcare operations.
    • The HIPAA privacy rule also gives patients the right to see, get a copy of and amend their medical record by adding information to it. To access the appropriate form, please click here.
    • For questions regarding the HIPAA rule or to file a complaint, please contact Rooks County Health Center’s Privacy Officer, Jamie Gosselin at 785-434-4553 during normal business hours.
  • Advance Directives
    • In compliance with the Patient Self Determination Act of 1990, it is the policy of Rooks County Health Center to inform the adult patient of their right to participate in their healthcare decision making. The following advance directives may be obtained from the HIM department or by clicking the links below.
    • Living Will – A document which allows an individual to request that life sustaining procedures be withheld or withdrawn and that he/she be allowed to die naturally should they be diagnosed with a terminal injury or illness.
    • Durable Power of Attorney for Healthcare Decisions – A document which allows an individual to name and agent to make healthcare decisions in the event the person completing the document becomes incapacitated.
Jamie Gosselin
Director HIM

Monday – Friday
8 a.m. to 4 p.m.

785-688-4413

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