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-r Ta 1� ,tt LSOtO. LEWIfi BU9rN E96 rOBM9, INC., JAa, rLA. 6 3 a ,.� :J ;h USE TYPEWRITER TO FILL IN THIAS FORM^ See Reverse Side for Instructions Ior Completing and Routing Form ��• t�`-, r+ APPLICATION AND AUTHORIZATION FOR Authorization N40? I : �,• x. HOSp1TALIZATIQN FOR THE INDIGENT i Florida State Board of Health and State Department of Public Welfare i SECTION A -PATIENT INFORMATION County of 11"Idence Patient's Kane Z---- --- Race_ SexAge _ Abr..4A,0 State Address_--. -- - erect Br r,FO City Next of kin or guardian Name Akiress Is patient a recipient of state public assistance? Yes No—: OAA—ADC—AB—AD Does patient have hospital insurance? Yes—No—Company? Any hospitalization in Florida in preceding 12 months? Yes No—___.__ How many days? Hospital City This is to certify (1) That I am a recipient of state public assistance and request admission to the hospital specified below OR, if not, that t am unable to pay the usual cost of tsospitalintw (2) That I do ibv agree that all hospital insuranu, voluntary mrtributions and part payments shall be assigned to the hospital for services provided. (3) That 1 hereby auttmriae the hospital art, hospital insurance carrin to make available to the Florida State Board of Health any requested information concerning medical, insurance, and financial records relating to my I+osDitatiaatiaL 1 t Signature t`ti "7d c �P r Kin Ulmss Irate 1'arrdt, Guardian, \est of Fin SECTION B -STATEMENT OF ATTENDING PHYSICIAN(S) This is to certify (1) That patient is acutely ill or injured and (2) That I recommend. admission for treatment under the hospitaliza- tion for the categoicaily or medically indigent program. T._Sehast]an..RivEr-Bedi.Cal Cgnter__Box-838-Sebastian_Florida —Ad,IreasotlPspHa1 Admitting diagnosis —ul"i,n& a��s C i erect Estimated length of hospitalization -a2 -----days. _ _.-- - .-gi f„i, ,,f ;tihndin rbyalrla� uate Hosaitalization recommended (Tumor Cases Only) sienatnre or i,in•rD-r of Tumor Clint, nztf — SECTION C -CERTIFICATION OF INDIGENCY (1) BY STATE DEPARTMENT OF PUBLIC WELFARE This patient is a recipient of public assistance and eligible for hospitalization. Remaining daps entitlement Case Name (if different from patient) Case Number — r a,iam llistrilt --- County-Appllrati 4 Nn. — Ceri i f i ed by - ____ ----- Position Date (2) BY IIEALTif DEPARTMENT OR OTHER AUTHORIZED AGENT This patient. with residency as indicated, has been investigated and is unable to pay the usual cost of hospitalization but he, his rela- tives or other: will pap towards the cost of hospitalization aS indieatcd below. Non Resident Resident In State for Under 1--, I_ 2 , 3 , 4 , 5 or more e-' years Part Pay promised: $ Per diem'.[] or Total El(check one) Signature of payor -- -- Address- - _ * -- ;Date Certified by _ -, ---- Positioner �- 1=- ==i�� f f Date- � SECTION D -AUTHORIZATION FOR HOSPITALIZATION 6 Payment for hospitalization is authorized from public fonds les, other payments or credits. The days authorized shall.lbe the mini- mum considered essential by the attending physician for t1w treatnwnt of the acute illness or injury. The maximurrr initially ap- proved is limited as indicated below but is not'to exceed I2 days. Additional days may be authorized below. Total authorizatior shall not exceed 30 days. Initial approval, days %atMnizmg Authority Date Additional approval, days_- : Total approved-----,,. iaa a wr z n n .r r Date SECTION E -CLAIM FOR SERVICES TO BFC-OMM-Er1• T) Ivy )iuties t At. V, -V.1 OF I'ATIENT ANI) FOUNVARDED TO THE AUTIfORIZING AUT1101tI'1'Y OP' Till, PATIENT'S i10ME COUNTY. Asan author-ized representative of_Sebasti an River Pedical Center Sebastian Fl. _-llosptlal - - city Lirra;c \n. I submit the followin claim for services authorized: 10-9-76 42 Rate per Day-MI-9-5— Date a .�� Date Admitted 8-2� 76- Date Discharged ------ Number of Days P y l 4 Amount due Less Net Amount Hospital S _ 6927.90— Credits: Insurance $-- Other $ of Claim $ 6 I hereby certify that the above statement is trite and correct; that the account is due; that no unlisted payment is due or has been received; and that there will be no additional charges. Primary Discharge Diagnosis `SECTION F-ENQORSED FOR PAY ENT Total $__ �"'' Initiatrd .tuih�rt;; in,; :5nthority DEC 151976- —__ Title. Fi nanaci al -Counselor.__ Date APPROVED FOR PAYMENT PAR $ ----- IISI $ nt Ito u of Qac=fi: 1 .•� : 479 Irate