Consent - New Patient Registration - **Please take note of the insurance plans we take below prior to completing the form**

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?

We allow patients to see all providers within the practice for sick/acute appointment. We allow parents the ability to split their kids up among multiple providers if they so choose. When it comes to annual checkups/wellness appointments, we prefer to keep the child with their primary provider unless you request to switch to another provider within the practice.

Dr. Sutton

Practice Partner

Emily Barker

Nurse Practitioner

Dr. Blatt

Practice Partner

Splitting among providers

please specify below:

State child & provider by using / or ()

Add Additional Child

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

Senders First Name

Senders 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.

Consent - New Patient Registration

Insurance Info

Attach Copy of Insurance & DL

Kid Approved Pediatrics