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KidsCARE

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Register for Swope Health KidsCARE


Child's Name
MM slash DD slash YYYY
Address
Gender
Race
Ethnicity
Language

Parent/Caregiver

Address same as child
Name(Required)
Address(Required)
My child

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)

Health Insurance (Child)

Do you have health insurance for your child?
Medicaid
Which provider?
Provider
Does your child have a primary care provider?
Commercial Health Insurance
Parent/Caregiver Above is Policy Holder
Commercial Dental Insurance
Parent/Caregiver Above is Policy Holder
Would you like Swope Health’s assistance in signing up for Medicaid for your child or family?
Would you like to enroll in Swope Health’s Sliding Fee Discount program or receive more information about financial assistance?
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
and my family size is
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:
MM slash DD slash YYYY
Consent to sliding scale(Required)
Is your family experiencing homelessness?
Would you like to learn about other Swope Health services, such as WIC, Maternal Health or Newborn care?
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 wish to designate a representative to accompany my child during the Mobile or School-Based visit in my absence.
Reset signature Signature locked. Reset to sign again
MM slash DD slash YYYY

 

It is the policy of Swope Health to serve all individuals who are eligible for its programs and services without regard to socio-economic status, race, national origin, color, religion, sex, sexual orientation, gender identity, disability (physical or mental), age, status as a parent or genetic information.
SHS Non-Discrimination Policy
Title VI Compliance Information
USDA Non-Discrimination Statement
FTCA Disclaimer

Central Facility

3801 Dr. Martin Luther King Jr. Boulevard
Kansas City, MO 64130
Phone: 816-923-5800

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It is the policy of Swope Health Services to serve all individuals who are eligible for its programs and services without regard to socio-economic status, race, national origin, color, religion, sex, sexual orientation, gender identity, disability (physical or mental), age, status as a parent or genetic information. SHS Non-Discrimination Policy | Title VI Compliance Information | USDA Non-Discrimination Statement | FTCA Disclaimer