Patient Forms

The following forms are available to assist you with expediting your first visit. Click on one of the forms below to learn more.

• Patient Information Form [PDF]
• Insurance Instructions [PDF]
• Medical Release [PDF]
• Physical Exam Forms [PDF]
• Privacy Practices [PDF]
• Child Care Health Form [PDF]
• Information Sharing Authorization (Parent Authorization) [PDF]

Refund Policy

It is the policy of Health Care For Children that payment is due at the time of service unless other financial arrangements are made in advance. We require ALL patients to pay their copay at the beginning of each visit, as required by your insurance company. If you do not carry insurance payment in full is expected at the time of service.

If your account has a credit balance after services rendered and a refund is approved, we will initiate the refund as soon as possible.

Pediatric Facility in Kansas City

Why choose a pediatric facility for your child’s health care needs? Because we are completely focused on providing pediatric care, which means that we have the knowledge and resources for what your child needs. Whether you are a new parent or need to schedule a sports physical, Health Care For Children can help.

Pediatric Care Concerns

Have a question about our patient forms or health care and pediatrician services? Call our Northland-based medical practice at (816) 792-1170 with inquiries.

Proudly serving the families of the Northland.