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Head Start

“Building partnerships, changing lives”

Child Health Form
Medical / Dental Home

Child’s Name: __________________________ D.O.B. __________

Medical insurance Providers
Insurance Type:

_______ CHIPS
_______ Medicaid
_______ Private: _________________________________
_______ Other (TriCare)
_______ No Coverage

Policy Number: _______________________________
Insurance Effective Date: _______________________
Primary Insurance: _______ Yes ________No
Dental Included: _______ Yes ________No

Current Medical Provider: _________________________________
Phone: _________________________________

Current Dental Provider: _________________________________
Phone: _________________________________

Hospital to use in case of an emergency:
____________________________________________

Disability Suspected Identified
Autism
Emotional/Behavior
Hearing Impairment
Learning Disability
IDD
Orthopedic Impairment
Vision Impairment
Speech or Language
Traumatic brain Injury

Revised: 4/2/18

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