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:

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

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

(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.

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