Having your Baby at Kapiolani - Page 10

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 ___________________________________________________________________________