Notification of Changes for Business Entity
General Information
Business Entity Name:	CHILD HEALTH CORPORATION OF AMERICA
Incorporation / Formation Date:	10/02/1985
FEIN:	52-1421302
Ohio License Number:	26928
NPN:	2758894
DBA / Trade Name:
State of Domicile:	DE
County:	JOHNSON
Business Address
Address 1:	6803 WEST 64TH STREET
Address 2:	SUITE 208
City:	SHAWNEE MISSION
State:	KS
Zip:	66202
Phone:	913-262-1436
Fax:	913-262-1575
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	6803 WEST 64TH STREET
Address 2:	SUITE 208
City:	SHAWNEE MISSION
State:	KS
Zip:	66202
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	NO	New DBA/Trade Name:
Amend DBA/Trade Name:	NO	Old DBA/Trade Name:
Add/Delete Producers, Members, Owners, Partners, Officers and/or Directors:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
ROBERT DAVIDSON, JR.	VICE PRESIDENT	6086795	YES

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date

Title Business Entities Only
1. Is any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance? (i.e. banking, auto dealer, mortgage company)
2. Has any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance since the filing of the previous CN-65 or the original application?
3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement

Submitted By
Submitted By:	DAVID SPIZMAN
Title:	SENIOR VICE PRESIDENT
Phone Number:	913-262-1436
Email Address:	DAVID.SPIZMAN@CHILDRENSHOSPITALS.ORG