5/14/1978 - Laserfiche WebLink

Home Browse Search

• FLJN1011 UU>,IYF ii iU1.Ya MI1IN YYI r.-.._. ' USE. TYPEWRITER TO FILLUE INTH See Reverse Side for Instructions for Completing and Routin �'j . APPLICATION AND AUTHORIZATION FOR Lj HOSPITALIZATION FOR THE INDIGENT •IF Authorization No. kal— Florida State Board of Health and State Department of Public Welfare Tndian Ri ver County of Residwe A -PATIENT INFORMATION /- t ,/ � ll e' A- . < Z ZI / / �iI 7I-) � Race _ Sexes_ Age--6(l- Patients Nam Winter Beach Florida Address PO Box 116 city Herkimer, NY Next of kin or guardian Margar9tR�OrOWski sister A,,e- Use am is patient a recipient of state public assistance? Yes XX OAA_ ADC AB AD No . Does patient have hospital insurance? Yes - No XX Company? Any hospitalization in Florida in preceding 12 months? Yew No X How many days? Hospita City Thla h to certify (1) That I am a recipient of state public assistance and request admission to the Imspital specified below Be, if -014 that 1 am o"ble to pay the now cost of hospitalization (2) DA 1 do heresy ava that all hospital iesmum voluntary contributions and part paseunts shall Ee rise* to the hospital for se,das presided. (3) That 1 Ircrehif authorise the hospital and hospital iapaam carrier to make milahle b the Florida State Board of Health airy requested irdormatimt con mft medical, insurance, and financial records rdatiaa to my hupiwiaation. Signature Si inature on f i 1 e Address Date Parent. Ceardion. Nest of Sia 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 categorically or medically indigent program. To Sebastian River Medical Center, Inc., PO Box 838, Sebastian,_ Florida 32958 pital A-01 Hospital Admitting diagnosisPulmonar 'r��fiii Estimated length of hospitalization 17 days si®atareofAtterviftPwsteiae Date Hospitalization recommended ( Tumor Cases Only) S1,,,ue of Dlmtar of Tensor clialc e 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 days entitlement Case Name (if different from patient) Case Number District .county Application No. I' Position Date Certified by (2) BY HEALTH 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 others will pay towards the cost of hospitalization as indicated below. Non Resident --—Resident Resiflent : In State for Under 1 1 2_ 3_-, 4 5 or more years Part Pay promised: perf tem ❑ or Total ❑ (check one) Signature of 10yor-Addresst 11 Certified by- SECTIOhi-'AUTHORIZATIOW FOR HOS'PI, ALIZATION Payment or hospitalization is authorized from public funds less other payments or credits. The days . Th died shall in the mini- mum considered essential by the att.ending physician for the treatment of the acute i.Uness or injury. The maximum initially ap- proved is -limited as indicated belo but is not to cxc d 12�sr Additional days ay be authorized below. Total authorization shall not exceed 30 da s. i ��,! Initial approval,/-Z,—days Auworltmg Aathnr 1/i fJ,j s Date_�"Z i� _� Additional approval, days -. Tota ovi d s . Jn]f,l"A� SECTION E -CLAIM FOR SERVICES To A ENT AND F lir IiOSYt1'AL UPON uD 1011,1 Itcs OF i'ATIN::CT AM1i) FOI;\CARisFD TO THE Al�Tll(A;I:IM1G - AUTHORITY OF THE I•ATIENT'S HOME COUNTY, As an authorized representative of Sebastian Medical Center. In_e. PO Box 8�$, 6actian, Fi 59-136 8 890 llo:puul city Lw;c a So. I submit the followin c aim for services authorized: y�fi3.39 Date Admitted 't �.2�8—Date Discharged -4--2.1!. —8 Number of Days --.17 --Rate per Da Amount due Less Net Amount Amount $.2,777,61-- -•Credits: Insurance $_0 Other $- 0 of Claim $___.2,777.63- -- I hereby certify that the above statement is true 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 Dial:nosislietaStatic carcinoma-prostate(operated)-..-Urina.ry_-retenti on, -Status _-posL colDstowy.'Aanemia.,_ur.inary-trart infection. CysinscopjL(-4-19_ZB) 5-1-75 sir:ned L/-- ul Date -- SECTION F -ENDORSED FOR PAYMENT APPROVED FOR PAYMENT Total .�Ja��. �t\ f. . PAR $— ---n'— `.,��'{•�\�,-�' t�.,t�NIL,IMa•1 .1111 nl: en7ltdatrl ill Uat¢ i 1 R� IHnwu.d �I•rtdl 11 1.1.01111).•1 ti'I'A'fF. LttlAf:U (>I 111:.1L'fll 11sl $ How... Ill N'ornl - Rev. 811 i62, MAY 2 4 t978 BOOK 35 PAGE 26