4615 Bryce Ave. Fort Worth, TX 76107
817-737-4000
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Attorneys
Dwayne W. Smith
Whitney Vaughan
Kenneth L. McAlister
Paige E. Lyons
Brooke Wilson
Terry Gardner
Practice Areas
Divorce
Child Custody
Custody Modifications
Grandparents Rights
Prenuptial Agreements
Resources
Divorce Information Form
Premarital Information Form
New Client Form
Health Insurance Availability Form
Contact
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Home
Attorneys
Dwayne W. Smith
Whitney Vaughan
Kenneth L. McAlister
Paige E. Lyons
Brooke Wilson
Terry Gardner
Practice Areas
Divorce
Child Custody
Custody Modifications
Grandparents Rights
Prenuptial Agreements
Resources
Divorce Information Form
Premarital Information Form
New Client Form
Health Insurance Availability Form
Contact
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Menu
Home
Attorneys
Dwayne W. Smith
Whitney Vaughan
Kenneth L. McAlister
Paige E. Lyons
Brooke Wilson
Terry Gardner
Practice Areas
Divorce
Child Custody
Custody Modifications
Grandparents Rights
Prenuptial Agreements
Resources
Divorce Information Form
Premarital Information Form
New Client Form
Health Insurance Availability Form
Contact
Health Insurance Availability
Name of Person Carrying Coverage
SSN
Besides each child's name, check all types of health insurance or benefits currently covering that child(ren).
I Understand
Child's Name
D.O.B.
SSN
Insurance/Benefit
Father's Insurance
Mother's Insurance
Private
Medicaid
CHIP
Other
None
Child's Name
D.O.B.
SSN
Insurance/Benefit
Father's Insurance
Mother's Insurance
Private
Medicaid
CHIP
Other
None
Child's Name
D.O.B.
SSN
Insurance/Benefit
Father's Insurance
Mother's Insurance
Private
Medicaid
CHIP
Other
None
Child's Name
D.O.B.
SSN
Insurance/Benefit
Father's Insurance
Mother's Insurance
Private
Medicaid
CHIP
Other
None
For each insurance source, please list the following:
Name if insurance company
Group Policy ID
Policy Holder and ID Number
Name of Child Covered
Cost of Premium to you (for children)
Are you paying the premiums?
Yes
No
Name if insurance company
Group Policy ID
Policy Holder and ID Number
Name of Child Covered
Cost of Premium to you (for children)
I agree that this is all correct to the best of my knowledge
I agree
Printed Name of Person Filling Out Form
Send
