ARRIVAL TIMESERVICE BEGINSDISPOSITION TIMEEMR CLASS
1 ::J 2 ::J3 ::J 4 ::J
120 WEST EIGHTH STREET - TELEPHONE 785 88S-4274ONAGA, KANSAS 56521
HOSPITAL 10 NO., OUTPATIENT
Please pnnt clearly.
SECONDARY INSUf'ANCE COMPANY AND ADDRESSPOLICY NO.SUBSCR~ERNAMEANDSSN
LOCATION ACCIDENT ~
PATIENT OR RESPONSIBLE PARTY EMPLOYER
EMPLOYER ADDRESS AND TELEPHONE
CLOSEST RELATIVE. ADDRESS AND TELEPHONEPARTY RESPONSIBLE FOR PAYMENT ADDRESS AND TELEPHONE
Q . . , . . l
1. CONSENT FOR EXAM AND TREATMENT.
This is to certify that
(We) the undersigned, consent to the performance of an examination and to the
treatment which may be deemed necessary in the opinion of the attending physician.
2 AUTHORIZATION TO PAY INSURANCE BENEFITS. I
hereby authorize payment directly to the Community Hospital Onaga, Inc. of the benefits otherwise
payable to me but not to exceed the Hospital's regular charges for this period of treatment. I understand that I am financially responsible to the
Hospital for charges not covered by this authorization.
3. AUTHORIZATION TO RELEASE INFORMATION.
I hereby authorize Community Hospital Onaga, Inc. to release my medical records or any othe'~ information requested by my insurance company in reference to this claim.
k A 1 0 .
C;!G'-;E_DFOR PT.BY~~~~----<.-.-------RELATIONSHIP -n1~EASON UNABLETO SIGN
TIME BP TEMP PULSE RESP MEDICATIONS