Expectant mothers looking forward to the arrival of their babies at Mount Nittany Medical Center will find the AS-503 Form, or Maternity Pre-Admission Form, a crucial step in preparing for their stay. This form is designed to streamline the admission process, ensuring that the Birthing Center staff can provide the best possible care from the moment of arrival. It gathers comprehensive information, including personal details, insurance information, and the expected due date, to minimize any administrative delays during this exciting yet stressful time. Additionally, it includes unique features like the option to set up a code word. This code word system is implemented to safeguard patient privacy while allowing loved ones to receive updates on the patient's condition, providing a balance between maintaining confidentiality and keeping family and friends informed. To facilitate a smooth admission, the form requests completion and submission at least two weeks before the due date, highlighting the center's commitment to preparedness and patient care. Moreover, this form touches on the need for linguistic and ethnic considerations, illustrating the center's dedication to accommodating diverse patient needs. Whether it's insurance billing queries or the desire for a specific spoken language support, the AS-503 Form serves as a comprehensive tool tailored to make the maternity experience as comfortable and efficient as possible.
| Question | Answer |
|---|---|
| Form Name | Form As 503 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | file 2005 mount nittany medical center form |
MOUNT NITTANY MEDICAL CENTER
1800 E. PARK AVENUE
STATE COLLEGE, PA 16803
ATTN: PATIENT ACCESS DEPARTMENT
(814)
MATERNITY
Thank you for choosing The Birthing Center at Mount Nittany Medical Center.
This form helps us plan for your admission to the Medical Center. Please provide insurance information so we can bill your insurance company. Please complete this form and return it at least two weeks before your due date. If you have questions, please call (814)
Date: ____________________________________
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Patient’s Name (Last) (First) (Middle)(Maiden)
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Address (Street) (City) (State)(Zip Code)
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Date of Birth Home Phone Work Phone Cell Phone
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Employer NameAddress
Social Security Number: ___________________________________
Marital Status: Single Married Divorced Separated
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If Married, List Spouse’s Name (Last) |
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(First) |
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(Middle) |
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____________________________________ ______________________________________________ |
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Expected Due Date |
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ObGyn Doctor |
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___________________________________________________________________________________ |
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Code Word (See back of this form for explanation) |
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Race: |
Black or African American |
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Asian |
White Declined |
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American Indian/Alaskan Native |
Native Hawaiian/Other Pacific Islander |
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Additional Race (if applicable): ____________________________________________________________ |
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Preferred Spoken Language: |
English |
Spanish |
French |
Chinese – Mandarin |
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Korean |
German |
Russian |
Pennsylvania Dutch |
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American Sign |
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Interpreter Needed: |
Yes |
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No |
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Ethnicity: |
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Hispanic or Latino |
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Not Hispanic or Latino |
Declined |
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Employer:
Name: _______________________________________________________________________
Address: _______________________________________________ Phone Number: ________________
Employee Status: ______________________________________________________________________
Next of Kin: |
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Name: _________________________________ |
Relationship: _______________________________ |
Address: _______________________________________________ |
Phone Number: ________________ |
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Person to Notify: |
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Name: _________________________________ |
Relationship: _______________________________ |
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Address: _______________________________________________ |
Phone Number: ________________ |
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Form No. |
Revised 7/1/11 |
Guarantor: |
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Name: _________________________________ |
Relationship: _______________________________ |
Address: _______________________________________________ Phone Number: ________________
Social Security #: _________________________
Employer Address: _______________________________________
Employment Status: _____________________________________________________________________
Subscriber: |
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Name: _________________________________ |
Relationship: _______________________________ |
Address: _______________________________________________ Phone Number: ________________
Employment Status: _____________________________________________________________________
Date of Birth: ______________________________ Social Security #: ____________________________
Insurance Information:
Please copy front and back of insurance card if possible. If card is not available, the following information is needed:
Policy #_____________________________________ Group #_______________________________
Admitting Physician Name: ___________________________________________
Attending Physician Name: ___________________________________________
Primary Care Physician Name: ___________________________________________
If More Than One Insurance Policy, List Additional Information Below:
___________________________________________________________________________________
Insurance Company Name |
Policy Number |
Group Number |
The Medical Center will bill your insurance company for your hospital care. You may need to give your doctor insurance forms to complete. Contact our Business Office at (814)
Are you a Penn State/University Park student? |
Yes |
No |
Are you a |
Yes |
No |
Print name of person completing this form: _________________________________________________
For Maternity care, please report directly to Labor and Delivery on the 4th floor.
Code Word
Many times, a patient at the hospital would like their medical information shared with those closest to them such as their grown children, church friends or other family members. Because of patient privacy and safety concerns, it has been impossible for the Medical Center to provide any more than a
A “code word” is a special word that patients give their family and friends allowing them to call the Medical Center and receive pertinent medical information about you.
How it works:
1.The patient chooses a word. Examples are: “snow cone”, “grandma”, “football”, etc.
2.The code word is recorded in the personal health record of the patient.
3.The patient communicates to their family and friends the code word.
4.Family and friends can call the nurses’ station, provide the code word and patient name. They will be given information about the patient and can talk to the nurse providing care. This will ensure effective communication.
5.You can change the code word at any time during your stay or at subsequent stays.
Patient privacy and safety is of utmost concern. The code word allows you to have control of who receives information about you. It also allows the physician and nursing staff to know that the person inquiring about the care is authorized by the patient to ask questions, receive information and know about your care.