PROVIDENCE HOSPITAL
PROCEDURE INFORMATION - REQUIRED FOR REGISTRATION
WHAT TYPE OF SERVICE ARE YOU REGISTERING FOR?
អ MATERNITY
អ DAY SURGERY
អ GENERAL SURGERY
PRE-ADMISSION FORM
FACILITY DIRECTORY
អ OTHER:
អ YES
អ NO
DATE OF ONSET
DIAGNOSIS/SYMPTOMS:
Heavy breathing; possible vertigo; displaying hypertension
EXPECTED DATE OF ADMISSION
June 16, 2019
ADMITTING PHYSICIAN:
June 21, 2019
P.O. BOX 196604 • ANCHORAGE, ALASKA 99519-6604
PHONE (907) 562-2211
IF MATERNITY, DATE OF LAST
MENSTRUAL PERIOD
Emil Soleyman, MD
THE COMMITMENT CONTINUES
PATIENT INFORMATION
PATIENT NAME
Last
First
MI
PREVIOUS NAME
GUEVARA, JAIME I
SEX
BIRTH DATE
M
N/A
SOCIAL SECURITY NUMBER
05/11/1984
PATIENT MAILING ADDRESS
MAR. STAT
145-86-8637
City
State
S
RACE RELIGION
L
Zip
IF YES, WHERE IS COPY KEPT?
POSSESS ADV.
DIRECTIVE?
1844 PROVINE STREET FORT WORTH, TX 76103
HOME PHONE
CHURCH AFFILIATION
OTHER:
EMPLOYER
WORK PHONE
MARRIOTT
RESPONSIBLE PARTY (IF OTHER THAN THE PATIENT)
LAST NAME
ADDRESS
FIRST
City
State
Zip
OCCUPATION
817-870-1000
ADMIN
FOLD HERE
DATE OF BIRTH
MI
អ PROVIDENCE
SEX
SOCIAL SECURITY NUMBER
HOME PHONE
WORK PHONE
EMERGENCY CONTACT
LAST NAME
FIRST
MI
HOME PHONE
GUEVARA, JANETH
HAVE YOU EVER BEEN IN THE MILITARY?
ARE YOU USING YOUR VA MEDICAL BENEFITS?
If yes, then you must complete a VA 1010.
SELF PAY?
YES
YES
WORKMAN'S COMPENSATION?
(If yes, please complete next four blocks.)
YES
NO
WORK PHONE
REL. TO PATIENT
201-617-1129
SISTER
ARE YOU ELIGIBLE FOR ALASKA NATIVE BENEFITS AT ANS HOSPITAL?
NO
YES
N/A
NO
YES
WORKMAN'S COMP. CARRIER
ARE YOU A U.S.
CITIZEN?
NO
DATE OF INJURY
YES
NO
CLAIM NUMBER
NO
⎯ REMEMBER TO PRE-AUTHORIZE WITH YOUR INSURANCE COMPANY! ⎯ INCLUDE MEDICAID INFORMATION
INSURANCE 1
PRIMARY INSURANCE NAME
PRIMARY INSURANCE ADDRESS
City
State
Zip
CIGNA HEALTH AND LIFE INSURANCE CO.
SUBSCRIBER NAME (Insured Person)
JAIME GUEVARA
SUBSCRIBER EMPLOYER
MARRIOTT/RENAISSANCE WORTHINGTON
INSURANCE 2
SUBSCRIBER NUMBER
GROUP NUMBER
U6630855301
SUBSCRIBER WORK PHONE
SUB. SEX
3141424
F
SUBSCRIBER DATE OF BIRTH
817-870-1000
Part-Time
Not Employed
Self-Employed
Retired
Active Military
HOW RELATED TO AUTHORIZATION #?
PT.?
05/11/1984
SELF
FOLD HERE
PRIMARY INSURANCE NAME
PRIMARY INSURANCE ADDRESS
SUBSCRIBER NAME (Insured Person)
SUBSCRIBER NUMBER
City
State
Zip
GROUP NUMBER
SUB. SEX
F
SUBSCRIBER EMPLOYER
M
EMPLOYMENT STATUS (Check One)
Full-Time
SUBSCRIBER WORK PHONE
SUBSCRIBER DATE OF BIRTH
M
EMPLOYMENT STATUS (Check One)
Full-Time
Part-Time
Not Employed
Self-Employed
Retired
Active Military
HOW RELATED TO AUTHORIZATION #?
PT.?
INSURANCE 3
PRIMARY INSURANCE NAME
PRIMARY INSURANCE ADDRESS
SUBSCRIBER NAME (Insured Person)
SUBSCRIBER NUMBER
City
State
Zip
GROUP NUMBER
SUB. SEX
F
SUBSCRIBER EMPLOYER
8561-008 (Rev. 11/07)
SUBSCRIBER WORK PHONE
Fold and Seal
M
EMPLOYMENT STATUS (Check One)
Full-Time
Part-Time
Not Employed
Self-Employed
Retired
Active Military
SUBSCRIBER DATE OF BIRTH HOW RELATED TO
PT.?
AUTHORIZATION #?
Cosmetic Surgeries
Elective inpatient and outpatient cosmetic surgeries require payment in full at time of registration. If your
insurance has determined that this is a covered service and a payment authorization is obtained prior to
registration, the balance due at point of registration will be the expected balance remaining after insurance.
The Mission of the Sisters of Providence
Providence Alaska Medical Center is owned and operated by the Sisters of Providence. It is a part of a
network of not for profit care giving agencies, through which, the Sisters work to fulfill their mission ⎯ to
make necessary health care services available to all individuals regardless of their ability to pay. The Sisters
of Providence have been servicing people throughout Alaska since 1902.
If your hospital bill is a financial hardship, please let us know. We will be happy to work with you to establish
an equitable payment arrangement or to assist you in applying for other assistance programs.
Providence Alaska Medical Center is a member of the Catholic Hospital Association.
PLACE
POSTAGE
STAMP
HERE
ADMITTING DEPARTMENT
PROVIDENCE ALASKA MEDICAL CENTER
PO BOX 196604
ANCHORAGE AK 99519-6604