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:

LaDonna Shetterly
Director HIM/Privacy Officer
Monday – Friday
8 a.m. to 4 p.m.
P.O. Box 389
Plainville, KS 67663

Important Things to Know About Pricing Information

RCH understands that hospital pricing and charges can be complex and difficult to understand. We are committed to providing patients and family members with information to help you understand hospital charges.

What a patient owes for a hospital procedure or service can vary greatly, depending on health insurance coverage, eligibility for state or federal programs and each individual’s own personal situation.

  1. “Charge” is not the same as what you may owe. “Charge” is the amount billed for a service.
  2. Because each person’s health needs are different, the charges shown will depend on the individual’s specific situation. Each patient’s circumstances are different, and one patient’s charge for a particular service may not necessarily be the same as another patient’s.
  3. If you have Health Insurance: Health Insurance will pay for many of your health services, but not all of them. Begin by contacting your insurance company to understand your insurance policy’s deductible, co-payment, coinsurance and maximum out-of-pocket levels. To avoid out-of-network penalties, check to see if you are required to use hospitals that are in your insurance company’s network. In addition, ask if you need to obtain pre-certification or referral approvals prior to your hospital service. This will help you avoid your policy’s penalties and additional amounts owed when the required approval is not obtained. Some insurance companies negotiate discounts with hospitals on behalf of the patients they insure. The discounts will vary among insurance companies.

Pricing Transparency

The RCH Charge List  lists all of the charges which could occur at RCH. Disclosure of the Charge Listing is required by federal regulation. You may incur one or a combination of these charges depending on your personal medical situation.
Charge information is for informational purposes only and should not be used as the sole criteria when making health care decisions.

Your Rights and Protections Against Surprise Medical Bills

To download a copy of Your Rights and Protections Against Surprise Medical Bills, please click here.

Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don’t have  insurance or who are not using insurance an estimate of the bill for medical  items and services.  

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. 
  • Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service. 
  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. 
  • Make sure to save a copy or picture of your Good Faith Estimate. 

For questions or more information about your right to a Good Faith Estimate, visit or call 1-800-985-3059.

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 patients’ 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 Inspect or Copy 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) was signed into law on August 21, 1996. 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. To access the appropriate form, please click here.

    • The HIPAA Privacy Rule went into effect on April 14, 2003 and 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, LaDonna Shetterly at 785-688-4413 during normal business hours (M-F 8-4 PM).

  • 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.