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 firstname.lastname@example.org.
2021 Financial Assistance Application (pdf)Download
2021 Financial Assistance Application Spanish (pdf)Download
Financial Assistance Program and Collection Policy - 2021 Update (pdf)Download
2021 Plain Language Summary (pdf)Download
Solicitud de Asistencia Financiera (pdf)Download
2021 Programa de asistencia financiera y política de cobranza (pdf)Download
2021 Plain Language Summary Spanish (pdf)Download
FAP Appendix A - Updated January 2021 (pdf)Download
APPENDIX B 2021 (pdf)Download
APPENDIX C 2021 (pdf)Download
APÉNDICE C (pdf)Download
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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 email@example.com