(409) 489-9322

1002 Dickerson Dr, Jasper, TX 75951 - view map 
Clinic Hours: Monday - Friday 8 am - 5 pm
Fax Number: (409) 489-9356

INSURANCES ACCEPTED 

• Most commercial insurances
• Molina CHIPS (Southern Counties only including Polk, Jasper, Tyler, Walker, San Jacinto and Newton)
• Superior Medicaid (Foster kids only)
• Molina Medicaid (Southern Counties only including Polk, Jasper, Tyler, Walker, San Jacinto and Newton)
• Texas Children’s Medicaid (Southern Counties only including Polk, Jasper, Tyler, Walker, San Jacinto and Newton)
• Texas Children’s Star Kids Medicaid
• Texas Children’s Chips (Southern Counties only including Polk, Jasper, Tyler, Walker, San Jacinto and Newton)
• Traditional Medicaid
• Coming Soon: Champus And Tricare

CHILDREN’S CLINIC FORMS 

• New Patient Form
• Patient Info Form
• Required Information Check in list
• Medical Info Form
• Family Medical Info Form
• Medical Info Release Form
• Authorization of Third Party Form
• Notice Concerning Complaints Form
• Treatment Form
• TVFC Screening Form
• HIPPA Form
• ImmTrac Form
• Health Insurance Claim Form