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El camino hospital maternity registration

Pre-admission record form - El Camino Hospital 2025

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The document is a pre-admission record form for patients entering a hospital, requiring completion and submission to the Patient Registration Department along with current insurance information. It collects essential patient details, including personal information, insurance coverage, emergency contacts, and employment status.

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Click ‘Get Form’ to open the Pre-admission record form in the editor.
Begin by entering your Patient Information. Fill in your legal name, date of birth, and contact details. Ensure accuracy as this information is crucial for your hospital admission.
Indicate your physician's name and the date you are scheduled to enter the hospital. If applicable, check the maternity box.
Provide insurance details by filling out the Primary Insurance section. Include the insurance company name, identification number, and group number.
If you have secondary or supplemental insurance, complete that section similarly. Make sure to include all relevant details for verification.
For work-related injuries, fill in employer information and any industrial insurance details if applicable.
Finally, review all entered information for accuracy before saving or submitting the form through our platform.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (60 Votes)
2009	4.1 Satisfied (62 Votes)

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