Call us at 219 947 3030
HOME   l   ABOUT US   l   CAREERS   l   CONTACT US
User Left Menu

 

Health Information

WebMD
 
 
HIND GENERAL HOSPITAL

101 W. 61st Ave.
Hobart, In 46342

Main Tel (219) 947-3030        Main Fax (219) 947-3838
Out Pt (219) 945-4991          In Pt (219)945-4990
Scheduling Fax (219) 947-5858
Patient Information:
 
       
 
Patient’s Name:
  
       
  Phone:   - -
       
 
Address:
  
       
  City:  
       
  State:  
       
  Zip Code:  
       
  D.O.B:   - -
       
  Age:  
       
  Sex:  
       
  Status:  
       
  SS#:   - -
       
  Referred By:  
       
  Emergency Contact:  
       
  Phone:   - -
       
  Address:  
       
  Relation:  
       
     
Pre-OP/Admitting Diagnosis:
 
  Type of Admission:   In Pt Out Pt  
       
  Planned Procedure:  
       
  Surgeon/Physician:  
       
  Asst:  
       
  Anesthesia Type:  
       
  Diagnosis:  
       
  ICD- 9 Code(s):  
       
Primary Insurance & Employment Information –Please include copies insurance cards:
 
 
Insured’s Name:
  
       
 
D.O.B Of Insured:
   - -
  OR    
 
SS# Of Insured:
   - -
       
  Relationship to Patient:  
       
  Employer Name:  
       
 
Employer Address:
  
       
  City:  
       
  State:  
       
  Zip:  
       
  Policy #:  
       
  Group Number:  
       
  Benefits#:  
       
  Insurance Carrier:  
       
  Address:  
       
  City:  
       
  State:  
       
  Zip:  
       
  Phone#:   - -
       
  
 
 
All Rights Reserved by Hind Hospital