KidsCARE

Register for Swope Health KidsCARE

Child's Name

First Middle Last

Date of Birth

School(Required)

Address

Street Address Address Line 2 City State ZIP / Postal Code

Phone

Gender

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

Language

Parent/Caregiver

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 Phone

Place 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 in

Medical (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

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

Commercial Health Insurance

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

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

Would you like to enroll in Swope Health’s Sliding Fee Discount program or receive more information about financial assistance?

Yes

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 is

Household Income

and my family size is

Household 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

Is your family experiencing homelessness?

Yes

Would you like to learn about other Swope Health services, such as WIC, Maternal Health or Newborn care?

Yes

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 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.

Name of Representative:

Parent/Legal Guardian Signature(Required)

Date

Register for Swope Health KidsCARE

Parent/Caregiver

Please check all services you are interested in

Health Insurance (Child)

Central Facility

Recent News