Patient Forms and Health Information

To enhance your experience with Cheyenne County Hospital we have provided online patient resources and information on your medical record.

Patient Forms

• Advance Directives - Durable power of attorney, Living Will
• DNR (Do Not Resuscitate) Directive - English and Spanish
• Grievance Form
• Notice of Privacy Practices - English and Spanish

Health Information

Privacy laws give you the right to see, get copies of, and sometimes even change your medical record.  The Cheyenne County Hospital health information department, or medical records, would be glad to accommodate you within the scope of the privacy laws.

To request copies of your medical records from Cheyenne County Hospital you may print the Authorization for Release of health Information form, complete it and fax to 785-332-2673 for mail to:

Cheyenne County Hospital
Health Information Management
PO Box 547
St. Francis KS  67756

Authorization for Release of Health Information

If you have any questions, please call 785-332-2104 Monday – Friday 8 a.m.-5 p.m. and request the Medical Records Department