Register for Swope Health KidsCARE Child's Name First Middle Last Date of Birth MM slash DD slash YYYY School(Required) Address Street Address Address Line 2 City State ZIP / Postal Code PhoneGender Male Female Other Race African American/Black Caucasian Asian Native American Alaska Native Native Hawaiian Pacific Islander More than one race (check all that apply) Other Ethnicity Decline Hispanic/Latino Non-Hispanic/Latino Language English Spanish Interpreter Requested Please Specify Please Specify Language Parent/Caregiver Address same as child Address same as child Name(Required) First Middle Last Relationship to Child Address(Required) Street Address Address Line 2 City State ZIP / Postal Code Home Phone(Required)Work PhonePlace of Employment Email(Required) My child Takes Medications Has Medical Conditions Has Food Allergies Has Allergies to Medications or Anesthetics Please Explain(Required)Please check all services you are interested inMedical (Well Child) Visit Complete Physical Exam Lead and Hemoglobin Test (Finger Stick) Immunizations Dental Visit Dental Exam Dental X-rays Cleaning Fluoride Application Sealants SDF (silver diamine fluoride for prevention of tooth decay)If you do not want any of these services - please list below.Health Insurance (Child)Do you have health insurance for your child? Yes No Medicaid Missouri Kansas Which provider?Provider Home State Healthy Blue United Healthcare (UHC) Sunflower Other DCN #: Does your child have a primary care provider? Yes No Commercial Health Insurance Parent/Caregiver Above is Policy Holder Parent/Caregiver Above is Policy Holder Parent/Guardian's Name of Policy Holder Name of Insurance Provider Place of Work Group # ID # Commercial Dental Insurance Parent/Caregiver Above is Policy Holder Parent/Caregiver Above is Policy Holder Policy Holder Relationship to Patient Company Group # ID # Please Specify Would you like Swope Health’s assistance in signing up for Medicaid for your child or family? Yes No Would you like to enroll in Swope Health’s Sliding Fee Discount program or receive more information about financial assistance? Yes No Sliding Fee DISCOUNT: If you are not insured, fees for services will be based on your household income and Family size. Charges may be reduced if you live on a limited income according to federal guidelines. We collect annual house hold income and Family size information to determine eligibility for a sliding fee discount. Charges for services which are not covered by Insurance may be eligible for sliding fee discount. SELF-DECLARATION OF INCOME AND FINANCIAL RESPONSIBILITY: I certify that my current annual household income isHousehold Income and my family size isHousehold Size I declare that all of my dependents are 18 years old and younger or disabled. I understand that this self-declaration is good for 30 days only. To receive a discount on services for a 12 month period, I will need to provide proof of my income by: proof of income date MM slash DD slash YYYY Consent to sliding scale(Required) I hereby certify that I have not knowingly withheld any information or income or other financial resources. The amounts I have disclosed are true and correct to my knowledge. I understand that hiding information or providing false information may result in prosecution or being removed from Medicaid, Medicare and any other Government funded programs. I understand the charges I have to pay for are after I received credit for all appropriate discounts and all collections received by Swope Health from health insurance benefits for the above-named individuals. I am responsible for the remaining balance. I agree to pay these charges on the day that the services are provided, within 10 days of receipt of the statement from Swope Health Services or by some other payment arrangement agreed to by the Swope Health Patient Relations Office, telephone 816-599-5700. I also authorize release of information about any claim to my health insurance carriers, or my state medical assistance agency and/or to the Department of Mental Health.(Required)Is your family experiencing homelessness? Yes No Would you like to learn about other Swope Health services, such as WIC, Maternal Health or Newborn care? Yes No I am voluntarily registering my child at Swope Health and consent to screening, and/or diagnostic and treatment services provided by (or at the direction of) a physician, Nurse Practitioner, Dentist, or other qualified health care professional of Swope Health. I will receive information advising me of my child’s health needs. I authorize the release of information for any applicable insurance coverage.(Required) I am voluntarily registering my child at Swope Health and consent to screening, and/or diagnostic and treatment services provided by (or at the direction of) a physician, Nurse Practitioner, Dentist, or other qualified health care professional of Swope Health. I will receive information advising me of my child’s health needs. I authorize the release of information for any applicable insurance coverage. I authorize Swope Health to share my child’s health information required for enrollment with my child’s school or center(Required) I authorize Swope Health to share my child’s health information required for enrollment with my child’s school or center I wish to designate a representative to accompany my child during the Mobile or School-Based visit in my absence. I wish to designate a representative to accompany my child during the Mobile or School-Based visit in my absence. Name of Representative: Parent/Legal Guardian Signature(Required) Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Δ
