TAP-TAM Site Application

Turn a Page. Touch a Mind.®

Early Literacy Program

Application to become a site

This is an application of request to the Kansas Pediatric Foundation (KPF) to become a Turn a Page. Touch a Mind®. (TAP‐TAM) literacy site in Kansas. KPF is the charitable arm of the Kansas Chapter, American Academy of Pediatrics, and provides funding to TAP‐TAM sites so that they can distribute books at well‐check visits from newborn through 5 years old. The information provided below will be presented to the KPF site selection committee for review. New site approvals are based on location, funding available, Medicaid/Medicare population served, and number of children served. Contact Michelle Horst at (913) 398-3388 or michelle.horst@kansasaap.org if you have questions.

Full Site/Practice Name: *

Type of Practice: *

Pediatrics

Family Physician

Other Other

Please list all participating physicians and other medical providers. *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Fax:

Email Address *

Website:

Insurance Coverage Information (Percentages need to total 100%)

Family Practice Applicants: complete the insurance percentages for your pediatric patients only ‐ not for your entire practice.

% Uninsured/Self Pay *

% Medicaid *

% Medicare *

% HMO Medicaid *

% HMO (Non-Medicaid) *

% Private Insurance *

% Other

(Define Other)

Estimated number of well-child visits ages 0‐5 years annually: *

Please list any local community organizations that KPF could partner with to support your practice *

Name of Site Coordinator *

Name of Physician Champion *

Signature of Physician Champion *

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