Insurance info form

VACCINE PROGRAM

As of January 2019, we are pleased to begin offering full-spectrum vaccines at our clinic thanks to our partnership with Vaxcare who will be managing all insurance billing services. If you would like to use your insurance to pay for your vaccines, please complete the form below.

All information is kept strictly confidential and only used to check on vaccination coverage at our clinic. Please call if you'd rather provide this information by phone or bring your information along to your next appointment.

See our vaccine program page for cash pricing and more details.

TIPS:
- Simply choose "self pay" if you prefer to pay cash OR if you use a health-sharing program (Liberty Healthshare, Samaritan, Medi-share, etc).
- Each family member needs to have a completed form.
- Please note that immunizations may need to be given at a separate visit if we do not have your information on file at the time of your visit. Thanks for your understanding!

* Indicates required field

Patient's first and last name *

Patient's date of birth MM/DD/YYYY *

Primary care physician at Health Suite 110 *

Name of health insurance company (or write "self pay") *

If you are SELF PAY, you can skip the rest!

Member ID *

Group ID *

Primary card holder's first and last name *

Primary card holder's date of birth MM/DD/YYYY *

Primary card holder's social security number *

Submit

7199 W 98th Terrace, Suite 110
Overland Park, KS 66212
Bldg #3 in Windmill Village
clinic: 913-948-7652
fax: 913-273-2474
hello@healthsuite110.com

Clinic Hours
Monday-Thursday 9am-5pm
Friday 9am - 12pm
After hours by arrangement

2019 Holidays - Clinic CLOSED
New Year's Day - Jan 1
Memorial Day - May 27
Independence Day - July 4-5
Labor Day - September 2
Annual Staff Retreat - August 2
Thanksgiving - November 28-29
Christmas - December 24-27
New Year's Eve - December 31

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