We apologize but we are unable to accept Cook Childrens STAR program or any program with state Medicaid including: Traditional MDCD, TMHP, or other Medicaid subprograms of AETNA, UHC and other private insurance companies. *
Guarantor Relationship to Patient: *
If you wish to add a second parent/guardian, please fill out the following information.
Otherwise, skip down to Emergency Contact Information.
Guarantor Relationship to Patient:
If you wish to add an Emergency Contact, please fill out the following information.
Otherwise, proceed to the next page.
AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN: I hereby authorize payment directly to the physician of the surgical and/or medical benefits, if any, otherwise payable to me for his/her services as described, realizing I am responsible to pay non-covered services.
AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize the physician to release any information acquired in the course of my treatment necessary to process insurance claims.