Patient Registration Form


Patient Registration Form

This application expires twelve (12) months from the date signed and must be resubmitted annually. 

Patient Name:

Patient Date of Birth://

Patient Sex: Text
 

Race: Text
  Ethnicity: Text
 

Address: , ,

Preferred Phone:   Alternate Phone:

If patient is a minor who is the legal guardian for child?  

Relationship:  

Emergency Contact Name:   Relationship:

Phone:  

PATIENT'S HEALTH INSURANCE INFORMATION

Are you part of a state or federally funded Program?

  If yes:

Do you have Shalom or Eskenazi Advantage (includes Pecar, Westside Clinic, Raphael, St. Vincent)?

 

Do you have private health insurance?

 

PRIMARY INSURANCE COMPANY:  

Name of Insured:  

Address:  

City, State, Zip:  

Phone Number:  

Birth Date: //

PATIENT'S EMPLOYMENT AND FINANCIAL INFORMATION

Employed

Military Status

Supported by:

  If Other/Name:  

Total Family Yearly Income:

 

Would you like to apply for Sliding Fee Scale?

 

List all Patients in the household, including Patient. 

AUTHORIZATION: I hereby authorize any bank or financial institution, government agency or department, hospital, physician, corporation or individual to furnish any information concerning this application to any authorized agent of Shalom Health Care Center, Inc.  Under penalty of perjury, I affirm the above information is true and correct to the best of my knowledge.  I further authorize the Shalom Health Care Center to release any information regarding services rendered by any provider to my health insurance company and, in case of Medicare, to the Centers of Medicare and Medicaid Services and its agents; and allow a photocopy of my signature to be used to file insurance, including Medicare, when applicable. I request that payment, including Medicare authorized benefits, be made on behalf to Shalom Health Care Center.  Regardless of my health insurance benefits, if any, I understand I am financially responsible for the fees for covered services and any costs incurred.  I further understand that if my account is turned over to a collection agency, I will be responsible for any interest charges allowed at the current legal rate, collection fees, reasonable attorney fees and court cost. 

THANK YOU FOR CHOOSING SHALOM HEALTH CARE CENTER, INC. 

Leave this empty:

Signature arrow
Shalom Health Care Center https://www.shalomhealthcenter.org
Signature Certificate
Document name: Patient Registration Form
lock iconUnique Document ID: 1fbf70b39bb37a582dc6c771def51a6a4331cb7f
Timestamp Audit
May 7, 2020 2:34 pm EDTPatient Registration Form Uploaded by Darren Huff - [email protected] IP 12.35.168.178