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.

Admission – Information Form 073124 (opens in new tab)
Admission – Information Form (Spanish) 073124 (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.