Consent - New Patient Registration

**Please take note of the insurance plans we take below prior to completing the form**

Please correct the errors described below.

Medical Insurance Plans ACCEPTED for Year 2021

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 2021

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

Which Provider are you looking to set as your child's PCP?

Add Additional Child

Address(If different)

Address(If different)

Required by Government Mandate

Insurance Info

Additonal Insurance

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