Foster Parent(s) Name:
Foster Parent(s) Address:
Foster Parent(s) Phone Number(s):
Date of Placement:
Case Manager Name:
Office Phone Number
Office Cell Phone
Office Fax Phone
Do providers have patient medical records? To provide appropriate medical care and meet KDHE
requirements, providers must have the patient's past medical history, including but not limited to:
Current health or development concernsCurrent medicationsAny known drug allergiesImmunizationsDate of patient's last physical/Well Child Exam
Do medical treatment facilities have the placement/guardianship papers for this patient on file?
Facilities must have these records in the patient’s chart to meet HIPAA regulations before seeing the patient.
Insurance Company Name
Policyholder's address (street, city, state, zip)
Policyholder’s home phone
Policyholder’s other phone
Policyholder's Address (street, city, state, zip)
Policyholder's Home Phone
Policyholder's Other Phone
If the patient does not have insurance coverage for the date services are provided:
Responsible party for payment of services:
All services, with the exception of hospital services, must be paid OR
an acceptable form of payment offered on the Date of Service.
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