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
785-688-4413

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  www.cms.gov/nosurprises/consumers 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.

Daniel J. Sanchez, MD

Specialty: Family Medicine

Bio:

Dr. Daniel Sanchez is a family medicine physician. He joined the staff at Rooks County Health Center in 1993. He enjoys preventive medicine — fixing risk factors before they cause problems.

He lives in Plainville with his wife, Karen, and their two children.

Education:

  • Residency: Family Medicine at Saint Joseph Hospital; 1993
  • Doctorate of Medicine: Loma Linda University; 1990
  • Bachelor of Arts in Theology/Chemistry Minor: Union College; 1986

Statement:

During medical training, I liked a bit of everything I did and Family Medicine became a very logical choice.  To follow a patient over many years, often treating generations of the same family, gives many insights into a person’s make-up–physically, mentally, emotionally and spiritually. 

I once asked a friend’s dad who was a general practitioner (the term used in that day) what his favorite part of medicine was and he told me preventative medicine.  I asked him what that meant and he said it was about helping people become and stay healthy so they wouldn’t get sick.  “Boring!” I thought.  I wanted to save lives, remove disease and do heroic things.

Now I understand.  We can really abuse our health and then bring our broken bodies for a doctor to try and heal, but how much better to take care of it in the first place and maintain it in good working order.  I understand my mentor’s line of thinking. 

My medical school’s motto is, “To Make Man Whole”.  That is my deepest desire, to restore the whole person to his or her greatest potential and maintain the highest quality of life possible.

Cynthia Peticolas, DMD

Specialty: Dentistry

Bio:

Dr. Cynthia Peticolas is a seasoned dental professional with over 30 years of experience. Dr. Peticolas was born in Maryland, but when she was a year old, her father landed a job with IBM and her family moved to Northern California. When she was in 6th grade her family relocated once again to Eugene, Oregon where her father worked as a physics professor at The University of Oregon. When it came time to go to college, the obvious choice would have been to go to her home-town college where her father worked, but instead she chose Oregon State University, 50 miles north, in Corvallis, Oregon.

She graduated with a Bachelor of Arts degree from Oregon State and then attended Oregon Health Sciences University in Portland where she received her dental degree in 1982.

Dr. Peticolas, practiced in Salem and Mill City, Oregon from 1982 until 2007 when she married and moved to Stockton, Kansas. She now lives in Damar, Kansas with her granddaughter and all her pets!! Anyone who knows her, knows how much she loves animals of all shapes and sizes. She is an avid horse-woman and enjoys trail riding (at a really fast trot). She attends local gaming events and has been active in the sport of endurance riding for nearly 25 years.

​Dr. Peticolas is still a student of dentistry and eager to learn and expand her knowledge and skills as a dental practitioner. She is a member of the American Dental Association, the Academy of General Dentistry, and is president-elect for the Kansas AGD for 2016.

Charles Schultz, MD

Specialty: General Surgery

Education:
University of Kansas School of Medicine 1979-1983
Residency- St. Luke’s Hospital/University of Missouri at Kansas City 1983-1989
Doctorate of Medicine- University of Kansas School of Medicine 1983

Board Certified:
American Board of Surgery

Lavelle Ellis, MD

Specialty: Gastroenterology

Medical School:
University of Kansas School of Medicine, 1986

Fellowship:
Wayne State University,
Gastroenterology
Royal Free Hospital, Hepatology

Residency:
University of Kansas School of Medicine, Internal Medicine

Board Certifications:
American Board of Internal Medicine, Internal Medicine and Gastroenterology

Memberships:
American Gastroenterological Association, American College of Gastroenterology,
American Association of Liver Disease.

Luann Evert, APRN

Specialty: Cardiology

Education and Training

Medical Degree(s)

Masters in Nurse Practitioner and Nursing Education, Fort Hays State University, Hays, KS
BSN, Fort Hays State University, Hays, KS

Patricia Crawley, MD

Specialty: Cardiology

Specialty:
Cardiology

Medical School:
University of Kansas School of Medicine, Kansas City

Residency:
Internal Medicine, University of Kansas School of Medicine, Wichita

Fellowships:
Cardiology, University of Tennessee Graduate School of Medicine, Knoxville

Board Certified:
Internal Medicine, Cardiovascular Disease

Scot Bandel, DPM

Specialty: Podiatry

Bio:

Dr. Bandel is Board Certified by the American Board of Foot and Ankle Surgery in the area of Foot Surgery. He is a member of the American College of Foot and Ankle Surgeons and the American Podiatric Medical Association.

Dr. Bandel is a Western Nebraska native, who attended undergraduate school at Chadron State College, in Chadron, Nebraska and then went on to pursue a Doctor of Podiatric Medicine at Des Moines University. In 2006, Dr. Bandel completed a 3-year surgical residency at Hennepin County Medical Center, a Level 1 Trauma Center, in Minneapolis, Minnesota.

​Dr. Bandel treats a vast number of foot and ankle ailments, both surgical and non-surgical, including but not limited to plantar fasciitis, hammertoes, bunions, sprains, fractures, and diabetic foot care needs. 

​During his time not spent with patients, Dr. Bandel is a very active member of his church and enjoys camping and spending time with his family.

Leann Zimmerman, APRN

Specialty: APRN
Location: Rooks County Hospital

Bio:

Leann Zimmerman, APRN, is a family and psychiatric nurse practitioner who has been providing health care services for over 30 years in rural Kansas.  She also provides a wound care clinic service for inpatients and outpatients at Rooks County Health Center.

Her clinical interest is being a patient advocate and providing care that makes a positive difference in others’ lives.

She lives in Hays with her husband, Jayme. They have 6 children. She enjoys many sports and family events.

Education:

Bachelor of Science in Nursing- Fort Hays State University

Master’s Degree in Counseling- Fort Hays State University

Master’s Degree in Nursing- Fort Hays State University

Clinical Nurse Specialist, Psychiatric Mental Health- Wichita State University

Family Nurse Practitioner- Fort Hays State University

Jerome M. Molstad, PA-C

Specialty: PA-C
Location: Rooks County Hospital

Bio:

With over 35 years of experience, Jerry was one of the first physician associate’s in Kansas to provide locum coverage to rural and small-town hospitals.

He spent most of his career supporting underserved areas and fulfilling his military obligations including separate deployments to Iraq and Kuwait.

A native of Colby, Jerry is always on the move enjoying hiking, skiing, travel, camping, flying, motor paragliding and John Deere equipment restoration. When possible he assists with EMS and firefighting. Jerry is the busy father of six.

Medical Education:

  • Doctorate of Medicine – University of Kansas School of Medicine 2016
  • Master of Public Heath – University of Kansas Medical Center 2014
  • Bachelor of Arts in Political Science – University of Kansas 2005
  • Bachelor of Science in Journalism – University of Kansas 2005

Military Education:

  • Air Command and Staff College
  • Air University, Maxwell AFB, AL (Squadron Officer School)

Certifications:

BLS, ACLS, ATLS, PALS, TCMC

Beth Oller, MD

Specialty: Family Practice
Location: Rooks County Hospital

Bio:

Dr. Beth Oller is a family medicine physician who graduated from Wesley Family Medicine Residency in Wichita.

She is delighted to work in the community of Stockton and build a practice at the new clinic. Clinical interests include maternal/child care, quality improvement, and rural medicine/access to care.

In her free time she likes to spend time with her family. She also likes to read, cross-stitch, and explore Kansas.

Education:

  • Residency: Wesley Family Medicine Residency Program; Wichita, KS; 2011
  • Doctorate of Medicine: University of Kansas School of Medicine; 2008
  • Bachelor of Science in Nursing: University of Kansas; 2002

Mike Oller, MD

Specialty: Family Practice
Location: Rooks County Hospital

Bio:

Dr. Mike Oller is a family medicine physician who graduated from Wesley Family Medicine Residency in Wichita.

He is pleased to live in the community of Stockton and excited to work at the new clinic. Clinical interests include quality improvement, chronic disease management, preventive and procedural medicine.

In his spare time he enjoys spending time with his family. He also enjoys nature photography and gardening.

Education:

  • Residency: Wesley Family Medicine Residency Program; Wichita, KS; 2011
  • Doctorate of Medicine: University of Kansas School of Medicine; 2008
  • Master of Public Health: University of Kansas; 2008
  • Bachelor of Science in Biology: Fort Hays State University; 2003

Emily Decker, PA-C

Specialty: PA-C
Location: Rooks County Hospital

Bio:

Emily Decker is a Physician Associate providing medical services at Rooks County Health Center’s walk-in clinic, Doctors Without Delay. She also worked several years as a Physician Associate at Rooks County’s Post Rock Family Medicine. In 2018 she rejoined the staff of Rooks County Health Center. Emily lives in Hays with her husband Thomas, and their son Grayson. Emily enjoys traveling, reading, crafting and spending time with her family & friends.

Education

  • Bachelor of Science in Mathematics from Fort Hays State University
  • Masters of Physician Assistant from Wichita State University

Certification:

  • Basic Life Support
  • Advanced Cardiac Life Support
  • Pediatric Advanced Life Support
  • Advanced Trauma Life Support