Hospital manual.

  • United States. Social Security Administration.
Date:
1967]
Catalogue details

Licence: Public Domain Mark

Credit: Hospital manual. Source: Wellcome Collection.

    85/130 (page 73)
    EXHIBIT 5 THE ADMISSION COPY OF THE INPATIENT PSYCHIATRIC OR TUBERCULOSIS HOSPITAL ADMISSION AND BILLING FORM DEPARTMENT OF HEALTH, EDUCATION, AND WELPARE SOCIAL SECURITY ADMINISTRATION S INPATIENT PSYCHIATRIC OR TUBERCULOSIS HOSPITAL ADMISSION AND BILLING — Approved. HOSPITAL INSURANCE BENEFITS - SOCIAL SECURITY ACT Ream abeae - PATIENT'S LAST NAME ; FIRST NAME “paste 2. HEALTH INSURANCE CLAIM NUMBER . PATIENT'S ADDRESS (Street number, City, State, Zip Code) 4. DATE OF BIRTH 8. SEX H ' (]™ Cle - HOSPITAL NAME AND ADDRESS 7. PROVIDER NO. 9. NAME AND ADDRESS OF ATTENDING PHYSICIAN 8. MEDICAL RECORD NO. « AOMITTED TO ACTIVE CARE| 11. NAME AND ADDRESS OF ANY INSTITUTION including this institution) IN WHICH PATIENT RECEIVED IN- ' : PATIENT CARE OURING LAST 60 DAYS (If this hospital, give dates of stay) ! ! ' | 12. NAME AND ADDRESS OF ANY PSYCHIATRIC OR TUBERCULOSIS INSTITUTION WHICH FURNISHED INPATIENT SERVICES AT ANY TIME DURING 90 DAY PERIOD PRECEDING EFFECTIVE DATE FOR HOSPITAL INSURANCE (If this hospital, give dates of stay) 13, PAYMEN T SOURCE FOR CHARGES TO PATIENT (SELF oR [BLUE cross (rustic asency FAMILY BLUE SHIELD (Give name) Insunance (_] Sw’ uwron (7) other (Explain) ——S})S SSS 14. PATIENT'S CERTIFICATION: AUTHORIZATION TO RELEASE INFORMATION AND PAYMENT REQUEST, I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize release of all records required to act on this request. I request that payment of authorized benefits be made on my behalf. SIGNATURE (Patient or authorized representative) (Signature by mark must be witnessed) DATE 18. ADMITTING OR CURRENT DIAGNOSIS EMPLOYMENT RELATED (J ves (No (If yes, give name and address of employer.) REPORT OF ELIGIBILITY J. Open Item Information Effective Date — Hospital Insurance ‘ 1. Intermediary Effective Date — Medical Insurance Full Coi Hospital Days Remaining ve fas ces ea Medical Plan Deductible [__] Met [__] Not Met Remaining Inpatient Deductible Pints Remaining Blood Deductible 2. Provider ECF Days Remaining 1 Medical HHA Visits Remaining I | Insurance Psychiatric Days Remaining Remarks 3. Date Admitted 4. Date Discharged INTERMEDIARY APPROVAL rorm SSA- 1485 (4-06) ADMISSION COPY