Providence Hospital Pre-Admission Form at a glance
What it is: Providence Hospital Pre-Admission Form: procedure information required for registration.
Where and when to file: Admitting Department, Providence Alaska Medical Center, PO Box 196604, Anchorage AK 99519-6604; place postage stamp here.
A filled-in Providence Hospital Pre-Admission Form example: a day surgery pre-admission
How to fill out Providence Hospital Pre-Admission Form, box by box
Procedure information, required for registration
Under What type of service are you registering for, check Maternity, Day Surgery, General Surgery or Other.
Enter the Diagnosis/Symptoms, the Date of Onset, the Admitting Physician and the Expected Date of Admission.
If maternity, enter the Date of Last Menstrual Period.
Facility directory
Under Facility Directory, check Yes or No.
Patient information
Enter the Patient Name (Last, First, MI), Previous Name, Sex, Birth Date, Social Security Number, Mar. Stat, Race, Religion and Church Affiliation.
Enter the Patient Mailing Address (City, State, Zip), Home Phone, Employer, Work Phone and Occupation.
Under Possess Adv. Directive, if yes, state where the copy is kept: Providence or Other.
Responsible party (if other than the patient)
Under Responsible Party (if other than the patient), enter the Last Name, First, MI, Date of Birth, Sex, Social Security Number, Address (City, State, Zip), Home Phone and Work Phone.
Emergency contact
Under Emergency Contact, enter the Last Name, First, MI, Home Phone, Work Phone and Rel. to Patient.
Military, VA, Alaska Native benefits and U.S. citizen
Check Yes or No: Have you ever been in the military?
Check Yes or No: Are you using your VA medical benefits? If yes, then you must complete a VA 1010.
Check Yes or No: Are you eligible for Alaska Native benefits at ANS Hospital? Are you a U.S. citizen?
Self pay and workman's compensation
Check Yes or No: Self pay? Workman's Compensation? If yes, please complete next four blocks: Claim Number, Date of Injury and Workman's Comp. Carrier.
Insurance 1, Insurance 2 and Insurance 3
Under Insurance 1, remember to pre-authorize with your insurance company and include Medicaid information; enter the Primary Insurance Name and Primary Insurance Address (City, State, Zip).
Enter the Subscriber Name (Insured Person), Subscriber Number, Group Number, Sub. Sex, Subscriber Employer, Subscriber Work Phone, Subscriber Date of Birth, How Related to Pt. and Authorization #.
Insurance 2 and Insurance 3 each have their own Primary Insurance Name.
More rules for Providence Hospital Pre-Admission Form
Elective inpatient and outpatient cosmetic surgeries require payment in full at time of registration.
If your insurance has determined that this is a covered service and a payment authorization is obtained prior to registration, the balance due at point of registration will be the expected balance remaining after insurance.
Common questions about Providence Hospital Pre-Admission Form
Where do I file it?
Admitting Department, Providence Alaska Medical Center, PO Box 196604, Anchorage AK 99519-6604; place postage stamp here.
Sources
[1] Providence Hospital Pre-Admission Form (Rev. 11/07), Providence Alaska Medical Center (the Official source link on this page).
