Printer-friendly version KidsCare Link physician & office staff registration form is this a request for a provider or for a delegate? Requestor Type: - None -ProviderOffice Staff access information Application Requested: - None -KidsCare Link requester information Requester First Name: * Middle Initial: Requester Last Name: * Phone: * business email address: * (you must enter a business email address. If you do not have one, please enter your manager’s business email address. We cannot accept Yahoo, Hotmail, Gmail or other private email accounts. This is a REQUIRED field.) clinic location information Office Name: * Address: * City: * State: * AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code: * Office Phone: * Fax: I have read, understand and agree to the policy * I have read, understand and agree to the policy Click here to read the policy!