KAP Provider Change Request

Please correct the errors described below.

This form is used to change your PCP within KAP or from another clinic if you have transitioned to KAP. This is required sometimes as proof to insurance so we may bill and treat the patient(s).

Add Additional Child

Person Requesting Change

Insurance Info

Attach New Copy of Insurance Showing PCP

    Please upload a file

    Provider Info

    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. **I understand that if my PCP is not updated and insurance denies a claim due to it I am responsible for the outstanding balance**

    This will be used for contact purposes only

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