Insurance Application
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Privacy Notice : © 2008 Annie Jeffrey Memorial County Health Center. All Rights Reserved. Site created by Midwest Marketing Services.
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
E: ceo.ajhc@gmail.com

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