Please present your insurance card and driver's license to an employee so we can update all information to ensure timely filing of your claim. If you do not have your insurance card with you, it’s your responsibility to contact the business office the next business day, with your correct information.
PATIENT INFORMATION:
Last Name
First Name MI Previous Name
DOB
Gender
Marital Status Race Language
Home Address
City
State
Zip
Phone
Cell
Employment Status
Occupation
Employer
Employer City
Employer Employer Phone
Email Address
HOW DO YOU WANT TO PAY FOR YOUR VISIT?
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INSURANCE INFORMATION:
Primary Insurance
Subscriber
ID#
Group#
Secondary Insurance
Subscriber
ID#
Group#
Tertiary Insurance
Subscriber
ID#
Group#
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GUARANTOR INFORMATION:
Last Name
First Name MI Previous Name
DOB
Gender
Marital Status Race Language
Home Address
City
State
Zip
Phone
Cell
Employment Status
Occupation
Employer
Employer City
Employer Employer Phone
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EMERGENCY CONTACT - PLEASE INCLUDE ONE CONTACT NOT AT YOUR RESIDENCE:
Contact 1
Relationship
Phone
Work Phone
Contact 2
Relationship
Phone
Work Phone
The undersigned has been informed of the treatment considered necessary for the patient and that the treatment and procedures will be performed by physicians, members of the house staff and employees of the hospital. Authorization is hereby granted to such treatment and procedures.
I certify that I, and/or my dependant(s), have insurance as indicated above and authorize benefits payable to Annie Jeffrey Memorial Health Center. I understand that I am financially responsible for all charges whether or not paid by the insurance company, and it is my responsibility to contact Annie Jeffrey Memorial County Hospital with any changes on my account.
Signed:
Date:
ANNIE JEFFREY HEALTH CENTER
531 BEEBE STREET
PO BOX 428
OSCEOLA, NE 68651
P: (402) 747-2031