Patient Notebook

KidsCare Home Health

14651 Dallas Parkway, Suite 200

Dallas, TX 75254

Phone: (866) 919 - 3240

Fax: (877) 300 - 7394

Website: www.kidscarehomehealth.com

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Error Summary

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1. Patient Information

First Name *

M.I.

Last Name *

Patient First & Last Name *

Patient Account #

Notes

Email Address

A receipt will be sent to this email address.

2. Payment Amount

Amount

3. Payment Method

Credit/Debit Card

Bank Account

Name on Card *

Card Number *

Expiration Date *

Security Code *

Zip Code *

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P (866) 919 - 3240

F (877) 300 - 7394

W www.kidscarehomehealth.com

14651 Dallas Parkway, Suite 200

Dallas, TX 75254