Registration Information Online Registration Form KCPCA Registration Form Patient Information * First Name Last Name Date of Birth * MM DD YYYY Gender * Male Female Other Primary Care Physician * With whom does the child reside? * Mother Father Step-Parent Foster Parent Grandparent Legal Guardian Other GUARDIAN #1 INFORMATION Guardian #1 Name * First Name Last Name Relationship to Patient * Mother Father Step-Mother Step-Father Grandparent Foster Parent Other Status of Parents Married Separated Divorced Widowed Unmarried Guardian #1 Date of Birth * MM DD YYYY Guardian #1 SSN# Guardian #1 Email * Guardian #1 Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Guardian #1 Phone Number * (###) ### #### Guardian #1 Employer Guardian #1 Work Phone (###) ### #### GUARDIAN #2 INFORMATION Guardian #2 Name First Name Last Name Relationship to Patient Mother Father Step-Mother Step-Father Grandparent Foster Parent Other Guardian #2 Date of Birth MM DD YYYY Guardian #2 SSN# Guardian #2 Email Guardian #2 Home Address Enter SAME if same address as above Address 1 Address 2 City State/Province Zip/Postal Code Country Guardian #2 Phone Number (###) ### #### Guardian #2 Employer Guardian #2 Work Phone (###) ### #### PRIMARY HEALTH INSURANCE Company Name Policy ID# Subscriber Name Subscriber Relationship to Patient Mother Father Step-Parent Other Subscriber Date of Birth MM DD YYYY SECONDARY HEALTH INSURANCE Company Name Policy ID# Subscriber Name Subscriber Relationship to Patient Mother Father Step-Parent Other Subscriber Date of Birth MM DD YYYY I authorize KCPCA to release any and all medical records, pertaining to my child's health, to my insurance company for any requested additional information. Yes No I hereby acknowledge that KCPCA has provided me with a copy of its Notice of Privacy Practices that describes how medical information about me/my child may be used and disclosed, and how I can access this information. (A copy is available on the KCPCA website) Yes No I acknowledge that I was provided with KCPCA financial policy and agree to the policy as stated. (A copy is available on the KCPCA Website). I understand that if I have questions or complaints, I may contact KCPCA. Yes No The physicians of KCPCA have my permission to provide my child/children with any necessary treatment. The following persons have my permission to seek medical attention for my child/children in my absence: SIGNATURE Parent/Legal Guardian Signature * Today's Date * MM DD YYYY Thank you for registering your child with KCPCA!
