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

Attach Copy of Insurance & DL

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