Blue KC Little Stars Referral Form

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* Required Field

Enter Member Information

  • Member First Name: *
  • Member Middle Initial:
  • Member Last Name: *
  • Member Date of Birth: *
  • Member Group ID: *
  • Member Due Date: *
  • Date of 1st Prenatal Visit:
  • Member Email Address:
  • Member Primary Phone Number: *
  • Enter a 10 digit phone number.
  • Member Alternate Phone Number:
  • Multiple Gestations
  • No Twins Triplets More

* Required Field

Enter Provider Information

  • Provider ID:
  • Provider's Name: *
  • Provider's Street Address:
  • Provider's City:
  • Provider's State:
  • Provider's ZIP Code:
  • Provider's Email Address:
  • Provider's Phone No:
  • Enter a 10 digit phone number.
  • Provider's Fax No:
  • Enter a 10 digit phone number.
  • Contact First Name:
  • Contact Last Name:
  • Contact Email Address:
  • Contact Phone Number:
  • Enter a 10 digit phone number.
  • Contact Phone Ext:
  • Contact Fax Number:
  • Enter a 10 digit fax number.

Today's Date:

Notes:

  • Checking this box will send a copy of your form to the email address provided.

If you experience issues submitting this form, please print and fax it to (816) 926-4215.

If you have questions, contact Blue KC at (816) 395-3964.

Cancel

Member Prefix

Your prefix is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

ID Number

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Suffix

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.

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