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Online Pre-Admission

Please fill out all appropriate fields below. All fields with a red asterisk (*) are REQUIRED. If you have any question about this form, please call Central Scheduling at (334)793-8754.
Online Pre-Admission
Patient Information
Last Name (*)
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First Name (*)
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Middle Name
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Maiden Name
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Gender (*)
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Marital Status (*)
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Date of Birth (*)
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Birth Place: County/State
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Social Security Number (*)
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Street Address (*)
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City (*)
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State (*)
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Zip Code (*)
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County
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County Patient Lives In
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Home Telephone (*)
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E-Mail Address
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Religion
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Name of Church
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Employer
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Patient Occupation
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How Long Employed
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Employer Address
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Employer's Phone Number
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Nearest Living Relative(Name)
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Relationship to Patient
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Phone Number
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Address
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Responsible Person: (GUARANTOR) The person responsible for any portion of the hospital bill not covered by insurance.
Last Name (*)
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First Name (*)
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Middle Name
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Street Address (*)
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City (*)
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State
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Zip Code (*)
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Phone (*)
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Relationship to Patient (*)
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Responsible Party SSN
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Responsible Person's Employer
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Occupation
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Employer's Phone Number
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Employer's Street Address
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Emergency Addressee: In event of emergency whom should we notify other than spouse or responsible party.
Last Name
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First Name
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Middle Name
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Street Address
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City
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State
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Zip Code
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Phome
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Relationship to Patient
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Emergency Person's Employer
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Employer's Phone Number
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Employer's Street Address
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Admission Information.
If previously a bed patient at SAMC, give date (or year) of last admission.
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Give name you were previously admitted under.
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Expected Date of Admission
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Room Preference
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Being hospitalized for?
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Does patient smoke?
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Does patient object to being with smoker?
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Veteran
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Has patient been in another hospital in past 12 months? (If yes, give name of hospital and date of admission)
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Name of Hospital
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Date of Admission
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Accident Information
Is this hospitialization the result of an accident?
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Where did the accident occur?
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Name of individual's residence or name of organization where accident occured.
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Address of Accident
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Date of Accident
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Name of person to contact concerning accident.
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Insurance and other sources of payment. NOTE: ANY DEDUCTIBLE AMOUNTS ARE PAYABLE AT ADMISSION
Blue Cross / Blue Shield
Contract Number
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Group Number
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Effective Date
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Policy Holder Name
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Subscriber's SSN
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State Issued
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Medicare Health Insurance: If you have medicare, please answer the following questions.
Medicare claim number
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Name as listed on Medicare Card
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Group Insurance: (Other than Blue Cross) carried through employer, union or association.
Name of Insurance Carrier
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Insured SSN
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Relationship to patient
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In whose name is the insurance carried?
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Name of employer through which insurance is carried?
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Phone Number
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Group Policy Number
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Certificate Number
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Medicaid Information: (Must present current monthly card on admission).
Name of individual card issued
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Medicaid number including suffix number
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Individual hospital insurance (other than Blue Cross). Premium paid directly to insurance company.
Name of Insurance Company
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Name of Insured Person
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Policy Number
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Policy Issue Date
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Champus Information Active or retired personnel wishing to file on Champus must furnish a non-availability statement for any scheduled admission. You will also need to present your military identification on admission to the hospital.
Sponsor's SSN
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Status
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Military Address for Active Duty Personnel
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Relationship to Patient
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Card Number
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Issue Date
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Expiration Date
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