Forms and Applications

Departments

Forms, Permits, and Applications Table
Title	Attachments	Submit Online
2023 CA-MED IRT Online Submission Forms	KMC IRT ITAC Form KMC Medical Privileges Request Form KMC Medical Staff Credentialing Application KMC Dental Staff Credentialing Application KMC Behavioral Health Credentialing Application KMC General Consent KMC Health Statement Form KMC Declination Influenza Vaccine KMC Declination Hepatitis B CA TB Risk Assessment IRT Staff Member Contact Information Form KMC Employment Application KMC Confidentiality Form KMC Emergency Contact Form KMC Employee Statement: Abuse KMC Mission & Vision Statement KMC Photo Release KMC PP Manual Receipt IHS Notice of PP KMC Background Form	Submit Online
Administration	KMC Annual Report Template KMC Annual Report Template KMC Semi Annual Report Template KMC Semi Annual Report Template Goals and SMART Objectives Tribal Project Development Data & Needs Assessment Form Civil Disturbance Incident Report
Agenda Request Form	KMC Governing Board Executive Summary Sheet Agenda Request Form
Assistance Programs	LIHEAP/LIHWAP Application 2023-2024 Emergency Assistance Form 2021-2022 KMC Energy Assistance Update for October 13.2022
Board Agenda Request Packet Online Submission	Executive Summary Form OTA Work Request Form agenda_request_form_2023.pdf	Submit Online
Clone of KMC Online Housekeeping Work Order		Submit Online
Contact Us		Submit Online
Cultural Path to Wellness Hupa Language Class Halloween Color by Numbers Online Submission	Kilwe-kyoh Kitse qe che-nehaw n Xutle-na mut Bose Color by Numbers Bo se liwhin	Submit Online
Fiscal Department	KMC FY2022 Budget Modification Form Cost Centers COA Cost Center Change Form
Health Information Management	KMC Notice of Privacy Practices KMC ROI
Human Resources	KMC Employee Evaluation Template KMC Personnel Policies KMC Employee Handbook KMC Screening Matrix KMC Vacant Position Form KMC Disciplinary Action Form
IT Department/ICS	ICS Contact Information Sheet KMC ITAC Form 2023
ITAC Form Online Submission	15_kmc-itac_access_form_rev_8.30.2023.docx	Submit Online
K'ima:w Medical Center Governing Board	KMC Governing Board Executive Summary Sheet
KMC Budget Modification Form Online Submission	KMC FY 2022 Budget Modifcation Form	Submit Online
KMC Employment and Volunteer Application	KMC Employment and Volunteer Application
KMC Employment Background Check Form	KMC Employment Background Check Form
KMC Events Checklist and Permissions	KMC Events Checklist and Permissions Form KMC Work Order Form Two Rivers Tribune Advertising Pricing	Submit Online
KMC Online Housekeeping Work Order		Submit Online
KMC Online Maintenance Work Order Submission Form		Submit Online
KMC Online Medication Refill Request		Submit Online
KMC Patient Comment Form Online Submission	KMC Patient Comment Form	Submit Online
MMIW & DV/SA Program: Intake Form Online Submission	MMIP Intake Form DV/SA Intake Form	Submit Online
New Patient Registration Paperwork Online Submission	New Patient Registration Page 1 New Patient Registration Page 2 General Consent HIPAA Consent Form	Submit Online
Online Employment Application Submission		Submit Online
OTA Work Request Form	OTA Work Request Form
Quality	KMC Notice of Privacy Practices KMC Patient Handbook TJC National Patient Safey Goals 2023 TJC National Patient Safety Goals 2023 Civil Disturbance Incident Report Patient Comment Form Incident Report Form
Submit a Bid		Submit Online
Supporting Departments	KMC Work Order KMC ITAC FORM 2023
Telephone Screening Form	Telephone Screening Form