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(620) 357-8361
809 W. Bramley St, P.O. Box 310 Jetmore, KS 67854
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O’Shea Memorial Clinic
Acute Care (Staffed 24/7)
Emergency Room (Staffed 24/7)
Radiology
Laboratory
General Surgery
Physical Therapy
Intermediate Swing Bed (Staffed 24/7)
Wound Care
Chiropractor (Tues/Thurs Mornings)
Transportation Bus
Pulmonary Rehabilitation Program
Skilled Swing Bed (SSB)
Pain Management
OUR COMMUNITY
PATIENTS & VISITORS
PARA Price Transparency Tool
Advance Directives
DNR: “Do Not Resuscitate Directive”
Durable Power of Attorney
Living Will
Patient Portal / Online Payment
No Surprise Billing Disclosure Form
Guide
Privacy Policy
Records Request
Patients Registration Form
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EMPLOYEE CORNER
Healthstream
Employee Email
ADP
EMR Login
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Volunteers
CAREERS
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CONTACT US
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ABOUT US
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Mission, Vision & Values
Providers
SERVICES
Menu Toggle
O’Shea Memorial Clinic
Acute Care (Staffed 24/7)
Emergency Room (Staffed 24/7)
Radiology
Laboratory
General Surgery
Physical Therapy
Intermediate Swing Bed (Staffed 24/7)
Wound Care
Chiropractor (Tues/Thurs Mornings)
Transportation Bus
Pulmonary Rehabilitation Program
Skilled Swing Bed (SSB)
Pain Management
OUR COMMUNITY
PATIENTS & VISITORS
Menu Toggle
PARA Price Transparency Tool
Advance Directives
Menu Toggle
DNR: “Do Not Resuscitate Directive”
Durable Power of Attorney
Living Will
Patient Portal / Online Payment
No Surprise Billing Disclosure Form
Guide
Privacy Policy
Records Request
Patients Registration Form
Chargemaster
EMPLOYEE CORNER
Menu Toggle
Healthstream
Employee Email
ADP
EMR Login
Join Us
Volunteers
CAREERS
BLOG
CONTACT US
Patient Registration Form
Patient Registration Form – Register Now
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O’SHEA MEMORIAL CLINIC PATIENT INFORMATION
Today’s Date
(Required)
Age:
(Required)
Sex:
(Required)
Patient Name:
(Required)
SS#:
(Required)
Address
(Required)
Street Address
ZIP
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
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Austria
Azerbaijan
Bahamas
Bahrain
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Belgium
Belize
Benin
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Bhutan
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Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
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Bouvet Island
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Chile
China
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Congo, Democratic Republic of the
Cook Islands
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Croatia
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Curaçao
Cyprus
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Côte d'Ivoire
Denmark
Djibouti
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Dominican Republic
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Egypt
El Salvador
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Estonia
Eswatini
Ethiopia
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Faroe Islands
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Finland
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French Guiana
French Polynesia
French Southern Territories
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Hungary
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Indonesia
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Iraq
Ireland
Isle of Man
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Italy
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Kenya
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Korea, Republic of
Kuwait
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Morocco
Mozambique
Myanmar
Namibia
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Netherlands
New Caledonia
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Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
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Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
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United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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Home #:
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Cell #:
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Email:
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DOB:
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Marital: M D S W
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Primary Language:
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Employer/Student:
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Employer Address:
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Phone #:
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City:
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School Name/Address:
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City:
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Do you have an Advance Directive (Examples: DNR, POA, Living Will, etc)?
(Required)
Yes
no
Unknown
INSURANCE INFORMATION
Please hand your card to the receptionist to be scanned
Insured Name (Policy Holder):
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Relationship:
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D. O. B.
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SS#:
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Primary Insurance:
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Policy #:
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Group #:
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I.D. #:
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Is this insurance through an employer?
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Yes
No
Employer Name:
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Address:
(Required)
Phone #:
(Required)
Secondary Insurance:
Insured Name:
Policy #:
Group #:
I.D. #:
PRIMARY REPSONSIBLE BILLING (GUARANTOR) PARTY
Name:
Relationship:
Phone #:
DOB:
SS#:
(Required)
Address
Street Address
City
State / Province / Region
Employer:
(Required)
Address:
PhoneEmployer Phone # :
City:
State:
SECONDARY REPSONSIBLE BILLING (GUARANTOR) PARTY
Name:
Relationship:
Phone #:
DOB:
SS#:
(Required)
Address
Street Address
City
State / Province / Region
Employer:
(Required)
Address:
PhoneEmployer Phone # :
City:
State:
EMERGENCY CONTACT
Emergency Contact Name:
(Required)
Relationship:
(Required)
Address:
(Required)
Phone #:
Consent for Treatment and Release of Information: I acknowledge that I do consent to have this information used as a basis for my care and treatment, arrange for billing and payment for my care and to arrange to carry out routine healthcare. I hereby authorize my attending physician or designee to administer such treatment and medications as are necessary in that provider’s opinion. This includes medical testing
I authorize the release of any medical information necessary to my insurance company. I agree to assign benefits to clinic. If insurance does not pay for this bill, I understand and agree that I am responsible for payment. If I do not have insurance, I understand I am responsible for this bill. I certify statements above in reference to credit are true and correct and I authorize investigation if necessary.
Responsible Party Signature:
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Witness:
(Required)
Date:
MM slash DD slash YYYY
I give O’Shea Memorial Clinic permission to discuss and or release my information to the following person(s) this choice may be changed at any time in writing:
Name:
Relationship:
Phone #:
Address
Street Address
City
State / Province / Region
Name:
Relationship:
Phone #:
Address
Street Address
City
State / Province / Region
Patient/Responsible Party Signature:
Date:
MM slash DD slash YYYY
Witness:
Date:
MM slash DD slash YYYY
Witness:
Date:
MM slash DD slash YYYY
ACUTE CARE
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EMERGENCY ROOM
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LABORATORY
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SURGERY
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RADIOLOGY
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CHIROPRACTOR
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TRANSPORTATION BUS
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WOUND CARE
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PHYSICAL THERAPY
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HOLISTIC PAIN
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INTERMEDIATE SWING BED
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