| PRIMARY INSURANCE
INFORMATION |
Name of
Insurance Carrier: _________________________________ Plan
Name: ___________________
Name of Insured: ____________________________ Patient
Relation to Insured: ___________________
Insured's Social Security #: ______/______/______ Insured's
Sex: 
Male
Female
Insured's Date of Birth: ______/______/______ Policy
#: ______________________________________
Group #: _______________________________ Group
Name: __________________________________
Claims Mailing Address:______________________________________
City:__________________________________ State:________________
Zip:_______________
Pre-Certification/Authorization Phone #: (_____ )___________
Benefits Phone #: (_____ )___________ |
| SECONDARY
INSURANCE INFORMATION |
Name of
Insurance Carrier: _________________________________ Plan
Name: ___________________
Name of Insured: ____________________________ Patient
Relation to Insured: ___________________
Insured's Social Security #: ______/______/______ Insured's
Sex:
Male
Female
Insured's Date of Birth: ______/______/______ Policy
#: ______________________________________
Group #: _______________________________ Group
Name: __________________________________
Claims Mailing Address:______________________________________
City:__________________________________ State:________________
Zip:_______________
Pre-Certification/Authorization Phone #: (_____ )___________
Benefits Phone #: (_____ )___________
(Please notify your insurance company for pre-certification
requirements. Failure to pre-certify result in a payment reduction
penalty. Please notify your insurance company of your impending
admission.) |
| NEWBORN PHYSICIAN
INFORMATION |
| *IT
IS VERY IMPORTANT THAT YOU SELECT A DOCTOR FOR YOUR BABY BEFORE
YOUR HOSPITAL ADMISSION* |
It is very
important to make sure that the pediatrician/family practice
physician you choose for your baby has medical staff privileges
that permits him/her to practice at your chosen hospital.
Please contact your medical plan/insurance provider representative
to ensure your selected pediatrician/family practice physician
is currently a member of your chosen hospital medical plan.
Thereafter, contact your selected pediatrician/family practice
physician before your hospital admission to make sure that he/she
is currently accepting new patients.
Be prepared to give the admitting registrar the name of the
physician you have selected to care for your baby at the time
of admission if there is not one named on this pre-admission
form. |
Physician's
Name: ___________________________________ Phone
#: (_____ )___________
Date you notified this physician: ______/______/______ |
|
Please
mail or fax this form immediately to:
|
Financial
Questions:
Baptist Medical Center
(210) 297-7616
Northeast Baptist Hospital
(210) 297-2621
North Central Baptist Hospital
(210) 297-4620
St. Luke's Baptist Hospital
(210) 297-5623
Southeast Baptist Hospital
(210) 297-3621 |
Registration
Questions:
Baptist
Medical Center
(210) 297-7610
Northeast Baptist Hospital
(210) 297-2626
North Central Baptist Hospital
(210) 297-4620
St. Luke's Baptist Hospital
(210) 297-5623
Southeast Baptist Hospital
(210) 297-3610 |
Baptist
Medical Center
111 Dallas Street
San Antonio, TX 78205
FAX: (210) 297-0701
ATTN: Pre-registration
Northeast Baptist Hospital
8811 Village Drive
San Antonio, TX 78217
FAX: (210) 297-0207
ATTN: Pre-registration
St. Luke's Baptist Hospital
7930 Floyd Curl Drive
San Antonio, TX 78229
FAX: (210) 297-0611
ATTN: WC Pre-registration
|
Southeast
Baptist Hospital
4214 East Southcross
San Antonio, TX 78222
FAX: (210} 297-0301
ATTN: Pre-registration
North Central Baptist Hospital
520 Madison Oak Drive
San Antonio, TX 78258
FAX: (210) 297-0401
ATTN: Pre-registration |
|
| We
look forward to the opportunity of serving you and your family |
