Please print and fill this form in order to provide a better and fast service.

• NOTICE OF PRIVACY PRACTICES
• Acknowledgement of notice of privacy practices
• Registration Form
• Medical History
• Patient Eligibility Screening Record Vacunes for Children Program

Payment is expected at the time of service. This includes these examples: when you have not met your deductible, or if you are a self- pay or have an 80/20 type plan and are responsible for apportion of your bill. If you are responsible for a co payment, it is expected when you sign in. It is always important that we communicate freely and confidentially about any financial concerns you have.

Kids Kare pediatrics staff will work with you to resolve any billing or insurance issues. If you have an outstanding balance with us or are having financial troubles, we can always work out some form of repayment plan that is mutually acceptable. We will file insurance claims for you.

Please help us by letting us know as soon as your insurance coverage changes. Remember to read your insurance plan as you would any other contract you would sign.
Insurance plans will provide only what they state they will provide and only the coverage you pay for. Make  sure  your insurance coverage allows your child to be hospitalized at the hospital of your choice.