Forms

Looking for a specific form? For your convenience, here are links to frequently used forms an individual or family may need to complete and return to FSGC.

Information Form (opens in new tab)
Information Form (Spanish) (opens in new tab)
Use and Disclosure Form (opens in new tab)
Use and Disclosure Form – Spanish (opens in new tab)
Admission/Discharge Permission and Consent Form (opens in new tab)
Medical Authorization Form (opens in new tab)
Health Checklist for Emergency/Temporary Care (opens in new tab)
Authorization for Emergency Medical Care (opens in new tab)
Autorizacion Para Cuidado Medico de Emergencia (Espanol) (opens in new tab)
Change of Address/Phone Number Form (opens in new tab)
Change in Insurance Form (opens in new tab)
Child Welfare Packet (opens in new tab)

Please note: If you have changed insurance companies, please download and complete the “Change in Insurance Form.”

If you’ve moved or gotten a new phone number, please download and fill out the “Change of Address/Phone Number Form.” Then return the completed form to FSGC at your next appointment. You can also scan the completed form and e-mail it to AccountsReceivable@FSGCtopeka.com.