Children's Mercy Kansas City -

Guarantor Change Request Form

At Children’s Mercy, guarantor is defined as the individual who is financially responsible for the patient, the primary contact for mail, and the primary contact for clinical information. There can only be one individual listed as the guarantor for a patient; the guarantor should be legal guardian of the child.
If you wish to change who is listed as the guarantor for a patient, please proceed with completing the form below.
Please note: if you have multiple children for whom you are requesting a guarantor change, you will need to submit a separate form for each child.

Patient Information:

Patient First Name

Patient Middle Name

Patient Last Name

Patient Date of Birth

Patient Address

Patient City

Patient State

Patient Zip Code

Information about the person you want to be listed as the guarantor:

Guarantor First Name

Guarantor Middle Name

Guarantor Last Name

Guarantor Date of Birth

Guarantor Address

Guarantor City

Guarantor State

Guarantor Zip Code

Guarantor Relationship To Patient

Are you enrolled in online bill pay (childrensmercy.patientsimple.com) to make regular payments to Children’s Mercy?

If yes, what email address(es) did you use to enroll? Please list all below

Please note, a guarantor change may impact your ability to access online bill pay; a change will also remove formal payment plan previously established.

Reason for guarantor change request

Full Name of person completing this form

Relationship to Patient

PhoneNumber

(Only to be used for follow-up communication from Children’s Mercy regarding your guarantor change request)

Attach any relevant court document(s). Please note, we may not be able to approve your guarantor change request without supporting documentation.

Attachments

"I have completed this form to the best of my knowledge. I have read and understand the definition of guarantor at Children’s Mercy, and I acknowledge it may take up to 10 business days for a request to be processed."

Signature

Printed Name

I acknowledge the above represents my electronic signature.

Guarantor Change Request Form

Patient Information:

Information about the person you want to be listed as the guarantor:

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