Insurance Application
About Us : Medical Staff : Patient Services : Employment : Visitor Info : Foundation : Clinics & Locations : Volunteers : Outpatient Clinics : Home
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
First Name MI Previous NameDOB Gender Marital Status Race Language
Gender Marital Status Race LanguageHome Address City State Zip
City State ZipPhone Cell
CellEmployment Status Occupation Employer
Occupation EmployerEmployer City Employer Employer Phone
Employer Employer PhoneEmail Address
HOW DO YOU WANT TO PAY FOR YOUR VISIT?
---------------------------------------------------------------------------------------------------------------------------------------------------------------------
INSURANCE INFORMATION:
Primary Insurance Subscriber ID# Group#
Subscriber ID# Group#Secondary Insurance Subscriber ID# Group#
Subscriber ID# Group#Tertiary Insurance Subscriber ID# Group#
Subscriber ID# Group#---------------------------------------------------------------------------------------------------------------------------------------------------------------------
GUARANTOR INFORMATION:
Last Name First Name MI Previous Name
First Name MI Previous NameDOB Gender Marital Status Race Language
Gender Marital Status Race LanguageHome Address City State Zip
City State ZipPhone Cell
CellEmployment Status Occupation Employer
Occupation EmployerEmployer City Employer Employer Phone
Employer Employer Phone---------------------------------------------------------------------------------------------------------------------------------------------------------------------
EMERGENCY CONTACT - PLEASE INCLUDE ONE CONTACT NOT AT YOUR RESIDENCE:
Contact 1 Relationship Phone Work Phone
Relationship Phone Work PhoneContact 2 Relationship Phone Work Phone
Relationship Phone Work PhoneThe 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:
Date:ANNIE JEFFREY HEALTH CENTER
531 BEEBE STREET
PO BOX 428
OSCEOLA, NE 68651
P: (402) 747-2031
