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If you would like to apply for financial assistance, please complete the form below. Once completed, contact Misty Kenton at Kiowa County Memorial Hospital business office (620)723-3341, or by email at mkenton@kcmh.net
2021 Financial Assistance Application (pdf)
Download2021 Financial Assistance Application Spanish (pdf)
DownloadFinancial Assistance Program and Collection Policy - 2021 Update (pdf)
Download2021 Plain Language Summary (pdf)
DownloadSolicitud de Asistencia Financiera (pdf)
Download2021 Programa de asistencia financiera y política de cobranza (pdf)
Download2021 Plain Language Summary Spanish (pdf)
DownloadFAP Appendix A - Updated January 2021 (pdf)
DownloadAPPENDIX B 2021 (pdf)
DownloadAPPENDIX C 2021 (pdf)
DownloadAPÉNDICE C (pdf)
DownloadCopyright © 2018 Kiowa County Memorial Hospital - All Rights Reserved.
Notice of Privacy Practices. This institution is an equal opportunity provider and employer.
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov
The next regular board meeting will be held on Friday, March 26, 2021 at 9:30 am.
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