Patient Registration Form
Ethnicity: Text Hispanic/LatinoNot Hispanic/Latino
Are you part of a state or federally funded Program? NoYes
If yes: Medicaid/Healthy Indiana Plan Medicare
Do you have Shalom or Eskenazi Advantage (includes Pecar, Westside Clinic, Raphael, St. Vincent)? NoYes
Do you have private health insurance?
PRIMARY INSURANCE COMPANY:
Name of Insured:
City, State, Zip:
Birth Date: //
Employed Full-Time Part-Time Temp Self-Employed Unemployed Disabled Retired
Military Status Active Veteran N/A
Supported by: Self Combined income: Self & Spouse Spouse Only Child Only Other
Total Family Yearly Income:
Would you like to apply for Sliding Fee Scale? YesNo
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.
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If you have questions about the contents of this document, you can email the document owner.
Document Name: Patient Registration Form
Agree & Sign