F
KAPI‘OLANI MEDICAL CENTER FOR WOMEN & CHILDREN
HONOLULU, HAWAII
PRE-REGISTRATION FORM
PURPOSE OF ADMISSION
MEDICAL
ADULT
SURGICAL
ADULT
MATERNITY
PEDIATRIC
PEDIATRIC
NO
ADMISSION DATE ______/ _________/_______ ADMISSION DATE SURGERY DATE ______/ _________/_______ ESTIMATED DATE OF DELIVERY _______/__________/ ______
LAST MENSTRUAL PERIOD ____ _______/__________/ ______
SELF
ADVERTISEMENT
_____________________________________
PHYSICIAN
PEDIATRICIAN (BABY'S DOCTOR)
EMPLOYEE
CLINIC _________________________________________________________________________
WHICH ONE ____________________________________ HOW MANY CHILDREN DO YOU HAVE? ____________________________________
OTHER _________________________________________ HOW MANY WERE BORN AT KMCWC? _____________________________________
YES NO
YES NO
DO YOU WISH CONFIDENTIALITY DURING YOUR HOSPITAL STAY?
YES NO
ARE YOU AN EMPLOYEE OF KMCWC?
LAST NAME
FIRST
PATIENT'S MAILING ADDRESS
CITY
SOCIAL SECURITY NO.
_______/__________/_______
_________________________________________________________________________
FRIEND
DO YOU HAVE AN ADVANCE DIRECTIVE?
PLEASE PRINT FULL LEGAL NAME
RACE
SEX
MAR. STATUS
BIRTHDATE
HAVE YOU (OR THAT PATIENT) BEEN
HOSPITALIZED WITHIN THE LAST YEAR? IF SO
WHAT HOSPITAL ____________________________
CITY, STATE ________________________________
MIDDLE PREVIOUS OR MAIDEN NAME
STATE OR COUNTRY ZIP CODE
RELIGION
BUSINESS PHONE/EXTENSION
PATIENT'S EMPLOYER'S ADDRESS
CITY
IS THIS HOSPITALIZATION THE RESULT
YES
HOME PHONE
BIRTHPLACE
PATIENT'S OCCUPATION & EMPLOYER
OF AN ACCIDENT?
(REV. 8/03)
OBSTETRICIAN (YOUR DOCTOR)
HOW WERE YOU REFERRED TO KMCWC?
IF YES, UNDER WHAT NAME?
_____________________________________
WHEN (MONTH/YEAR)?
ITEM #8084
MATERNITY PATIENTS ONLY:
PHYSICIAN'S
NAME
________________________________________
WERE YOU (OR THE PATIENT) EVER
HOSPITALIZED AT KMCWC? (INCLUDE
IF YOU WERE BORN HERE).
YES
FORM # AD-40
SURGICAL PATIENTS ONLY
IF YES IS THIS
NO
GUARANTOR'S LAST NAME
AUTO RELATED
WORK RELATED ACCIDENT
FIRST
M.I.
ZIP CODE
DATE & TIME OF
SOCIAL SECURITY NO.
CITY
GUARANTOR'S MAILING ADDRESS
STATE OR COUNTRY
RELATION TO PATIENT
STATE OR COUNTRY
ZIP CODE
GUARANTOR'S OCCUPATION & EMPLOYER
SEX
HOME PHONE
BUSINESS PHONE/EXTENSION
GUARANTOR'S EMPLOYER'S ADDRESS
CITY
STATE OR COUNTRY
ZIP CODE
IN CASE OF EMERGENCY, NOTIFY: (LOCAL-ON ISLAND & NON-LOCAL-OFF ISLAND)
L
O
C
A
L
LAST NAME
FIRST
EMERGENCY CONTACTS HOME ADDRESS
L
N O
O C
N A
L
M.I.
HOME PHONE
LAST NAME
FIRST
CITY
M.I.
HOME PHONE
EMERGENCY CONTACTS HOME ADDRESS
RELATION TO PATIENT
RELATION TO PATIENT
CITY
POLICY NO.
PRIMARY INSURANCE-NAME
COVERAGE
EFF. DATE
POLICY NO.
EFF. DATE
STATE OR COUNTRY
BUSINESS PHONE/EXTENSION
STATE OR COUNTRY
ZIP CODE
GROUP
GROUP
POLICY IN NAME OF (LAST NAME, FIRST NAME, M.I.)
MEDICAID/DSSH RECIPIENT NUMBER
EFF. DATE
IF APPLICABLE, ATTACH OR BRING IN:
• MEDICAID COUPON AND PRIOR AUTHORIZATION
• INSURANCE IDENTIFICATION CARD & CLAIM FORM
ZIP CODE
POLICY IN NAME OF (LAST NAME, FIRST NAME, M.I.)
SECONDARY INSURANCE-NAME
COVERAGE
BUSINESS PHONE/EXTENSION
EXP. DATE
• CHAMPUS NON-AVAILABILITY FORM (DD-1251)
• AUTHORIZED PRECERTIFICATION FORM
• SECOND SURGICAL OPINION INFORMATION
ASSIGNMENT OF INSURANCE BENEFITS
I AUTHORIZE MY INSURANCE CARRIER(S) TO PAY DIRECTLY TO KAPI‘OLANI MEDICAL CENTER FOR WOMEN AND CHILDREN (KMCWC) ANY BENEFITS TO WHICH I MAY BE ENTITLED, I UNDERSTAND
AND AGREE TO BE FINANCIALLY RESPONSIBLE TO KMCWC FOR CHARGES NOT COVERED BY MY HOSPITALIZATION INSURANCE.
DATE ________________________
SIGNATURE OF GUARANTOR ___________________________________________________________________________