KAP Patient Registration

Medical Insurance Plans ACCEPTED for Year 2020

Aetna / All Savers / BCBS PPO-HMO-POS / BCBS Advantage / Cigna / First Health / Coventry Network/ Humana / Humana-Choice Care / Meritain Health / Scott and White Health Plan / Tricare Standard & Select / UMR / United Health Care

Medical Insurance Plans NOT ACCEPTED for Year 2020

Ambetter / Amerigroup / Aetna Better Health / Aetna Texas Health HMO / Chips / Cigna Local Plus / Cigna - Focus In Plan / Freedom Life / Liberty Healthshare / Medicaid / Molina / Parkland / Superior / Tricare Prime / UMR – Imagine Plan

Additional Patient

Address

City

State

Zip

Address(If different)

Mother - Parent/Legal Guardian

DOB

Contact #

Father-Parent/Legal Guardian

DOB

Contact #

Address

City

State

Zip

Address(If different)

Required by Government Mandate

Language

Race

Ethnicity

Send Statements to

Mom

Dad

Contact Preferences

Dad

Mom

Parent's Marital Status

Married Widowed Divorced separated Other

Insurance Info

Additonal Insurance

Attach Copy of Insurance & DL

File attachments

Add file

Please upload a file

Parent First Name

Parent Last Name

Electronic Authorization Signature

By signing this form, I attest that I have personally read this form (or had it explained to me) and fully understand and agree to its contents. Checking this box you are consenting the above name is legit and authorized guardian. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Parent Email:

Your information will be encrypted.

KAP Patient Registration

Insurance Info

Attach Copy of Insurance & DL

Kid Approved Pediatrics