Form 32 1013 A is a form used by the IRS to document an individual's annual income tax return. The form is also known as the Wage and Tax Statement, and it is used to report wages, tips, and other compensation received by an employee during the tax year. The form must be completed by employers and filed with the IRS annually. The deadline for submitting Form 32 1013 A is January 31st.Employers are required to provide their employees with a copy of Form 32 1013 A at the end of each year. The form provides important information about an individual's taxable income and taxes paid during the year. It is essential that taxpayers review their Form 32 1013 A carefully in order to ensure that they are accurately reporting their income and correctly calculating their tax liability.Anyone who has questions about how to complete or interpret Form 32 1013 A should consult a qualified tax professional.
| Question | Answer |
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| Form Name | Form 32 1013 A |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | st joseph hospital maternity registration, DURABLE, st joseph labor and delivery, st joseph hospital labor and delivery |
MatErnity |
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CHECK THE BOX OF THE HOSPITAL WHERE YOU ARE DELIVERING: |
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o St. Joseph Medical Center |
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(FOR MOTHER) |
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DUE DATE |
FAMILY PHYSICIAN |
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OBSTETRICIAN |
MIDWIFE |
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o St. Francis Hospital |
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PATIENT INFORMATION |
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PATIENT LEGAL NAME (LAST, FIRST, MIDDLE) |
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DATE OF BIRTH |
AGE |
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SOCIAL SECURITY NUMBER |
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PATIENT LEGAL ADDRESS |
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CITY, STATE, ZIP |
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HOME TELEPHONE |
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PATIENT EMPLOYER NAME |
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WORK TELEPHONE & EXTENSION |
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OCCUPATION |
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PATIENT EMPLOYER ADDRESS |
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CITY, STATE, ZIP |
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EMPLOYMENT STATUS |
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MARITAL STATUS |
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HAVE YOU BEEN A PATIENT AT ST. JOSEPH MEDICAL CENTER, ST. FRANCIS HOSPITAL, ST. CLARE HOSPITAL |
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UNEMPLOYED |
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SINGLE |
WIDOWED |
SEPARATED |
OR ST. ANTHONY HOSPITAL BEFORE? IF SO, WHAT NAME WAS USED? |
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RETIRED |
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MARRIED |
DIVORCED |
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EMERGENCY CONTACT (NAME TWO, NOT AT THE SAME ADDRESS)
NAME OF PERSON TO NOTIFY
ADDRESS
NAME OF PERSON TO NOTIFY
ADDRESS
RELATIONSHIP TO PATIENT |
HOME TELEPHONE |
WORK TELEPHONE & EXTENSION |
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EMPLOYER NAME |
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RELATIONSHIP TO PATIENT |
HOME TELEPHONE |
WORK TELEPHONE & EXTENSION |
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EMPLOYER NAME
PERSON WHO CARRIES PRIMARY INSURANCE AND/OR FINANCIAL RESPONSIBILITY FOR THIS HOSPITALIZATION
NAME (LAST, FIRST, MIDDLE)
ADDRESS
DATE OF BIRTH |
AGE |
SEX |
RELATIONSHIP TO PATIENT |
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CITY, STATE, ZIP |
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HOME TELEPHONE |
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EMPLOYER NAME
WORK TELEPHONE & EXTENSION
( )
OCCUPATION
SOCIAL SECURITY NUMBER
EMPLOYER ADDRESS
CITY, STATE, ZIP
EMPLOYMENT STATUS
UNEMPLOYED |
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RETIRED |
MARITAL STATUS
SINGLE WIDOWED SEPARATED
MARRIED DIVORCED
ADVANCE DIRECTIVE
DO YOU HAVE A LIVING WILL? |
DURABLE POWER OF ATTORNEY FOR HEALTH CARE? |
LOCATION OF LIVING WILL/DURABLE POWER OF ATTORNEY |
RELIGION |
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YES |
NO |
YES |
NO |
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PRIMARY INSURANCE |
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INSURANCE PLAN NAME |
ADDRESS |
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TELEPHONE |
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BRING |
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GROUP# |
SUBSCRIBER/POLICY/MEMBER # |
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INDIVIDUAL POLICY YES NO |
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CURRENT |
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COMMERCIAL PLAN |
POLICY # |
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GROUP # |
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MEDICAID |
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IDENTIFICATION |
BASIC HEALTH PLAN |
POLICY # |
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GROUP # |
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CARD, |
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HEALTHY OPTIONS |
POLICY # |
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CLIENT ID # |
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MEDICARE |
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DSHS |
CLIENT ID # |
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OTHER |
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AND/OR |
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INSURANCE |
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SECONDARY INSURANCE |
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INSURANCE PLAN NAME |
ADDRESS |
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TELEPHONE |
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CARDS AT |
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TIME OF |
SUBSCRIBER NAME (LAST, FIRST, MIDDLE INITIAL) |
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SEX |
RELATIONSHIP TO PATIENT |
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SOCIAL SECURITY NUMBER |
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ADMISSION. |
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GROUP # |
SUBSCRIBER/POLICY/MEMBER # |
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INDIVIDUAL POLICY |
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SOME INSURANCE SUPPLEMENTS/SECONDARY INSURANCE COMPANIES REQUIRE PREAUTHORIZATION FOR MAXIMUM HOSPITAL BENEFITS. |
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TO BE PREREGISTERED PRIOR TO DELIVERY, PLEASE EITHER ATTEND OUR WELCOME TO OUR HOME RECEPTION, MAIL THIS COMPLETED FORM, OR YOU MAY CALL US AT (866)
SIGNATURE: |
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DATE: |
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PEDIATRICIAN: |
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(FOR BABY) |