If you are traveling for a doctor's appointment, please let us know by filling out the information below. This helps us keep a record of your appointments and allows us to submit a claim to your insurance, in the case that you are eligible for reimbursement.

AFTER COMPLETION, PLEASE EMAIL A PICTURE OF YOUR DRIVER’S LICENSE TO KP@KAPAAPEDIATRICS.COM

Due to recent changes to HMSA travel requirements, we now need to collect additional information, such as your ID, to secure travel insurance approval. This may include your weight, which is sometimes required for smaller flights. Thanks for your cooperation!

Insurance

Patient Name - First Middle Last

First Name

Last Name

Date of Birth

Physical Address (NOT PO Box)

Name of Escort (parent) - FIRST MIDDLE LAST, EXACTLY ON LICENSE

Relationship to patient

Parent Phone #

(###)

###

####

Parent Email

Parent Date of Birth

Parent Weight

Date of Appointment

YYYY

Time of Appointment

Hour

Minute

Second

Type of appt (follow up, initial eval, surgery ect.)

Specialist Name

Department (cardio, ENT, derm ect.)

Specialist Address

Specialist Phone #

If there are mutliple appointments add that information here or add any additional notes

Additional comments (early check in/lap infant)

Travel

Air

Lodging (overnight stay)

Ground