The Institute for Women's Health
  Info (210) 349 - 9300 • 
PRIMARY INSURANCE INFORMATION
Name of Insurance Carrier: _________________________________    Plan Name: ___________________
Name of Insured: ____________________________    Patient Relation to Insured: ___________________
Insured's Social Security #: ______/______/______    Insured's Sex:      Male        Female
Insured's Date of Birth: ______/______/______    Policy #: ______________________________________
Group #: _______________________________     Group Name: __________________________________
Claims Mailing Address:______________________________________
City:__________________________________       State:________________         Zip:_______________
Pre-Certification/Authorization Phone #: (_____ )___________   Benefits Phone #: (_____ )___________
SECONDARY INSURANCE INFORMATION
Name of Insurance Carrier: _________________________________    Plan Name: ___________________
Name of Insured: ____________________________    Patient Relation to Insured: ___________________
Insured's Social Security #: ______/______/______    Insured's Sex:      Male        Female
Insured's Date of Birth: ______/______/______    Policy #: ______________________________________
Group #: _______________________________     Group Name: __________________________________
Claims Mailing Address:______________________________________
City:__________________________________       State:________________         Zip:_______________
Pre-Certification/Authorization Phone #: (_____ )___________   Benefits Phone #: (_____ )___________
(Please notify your insurance company for pre-certification requirements. Failure to pre-certify result in a payment reduction penalty. Please notify your insurance company of your impending admission.)
NEWBORN PHYSICIAN INFORMATION
*IT IS VERY IMPORTANT THAT YOU SELECT A DOCTOR FOR YOUR BABY BEFORE YOUR HOSPITAL ADMISSION*
It is very important to make sure that the pediatrician/family practice physician you choose for your baby has medical staff privileges that permits him/her to practice at your chosen hospital.

Please contact your medical plan/insurance provider representative to ensure your selected pediatrician/family practice physician is currently a member of your chosen hospital medical plan. Thereafter, contact your selected pediatrician/family practice physician before your hospital admission to make sure that he/she is currently accepting new patients.

Be prepared to give the admitting registrar the name of the physician you have selected to care for your baby at the time of admission if there is not one named on this pre-admission form.
Physician's Name: ___________________________________      Phone #: (_____ )___________ 
Date you notified this physician: ______/______/______

Please mail or fax this form immediately to:
Financial Questions:

Baptist Medical Center
(210) 297-7616

Northeast Baptist Hospital
(210) 297-2621

North Central Baptist Hospital
(210) 297-4620

St. Luke's Baptist Hospital
(210) 297-5623

Southeast Baptist Hospital
(210) 297-3621
Registration Questions:

Baptist Medical Center
(210) 297-7610

Northeast Baptist Hospital
(210) 297-2626

North Central Baptist Hospital
(210) 297-4620

St. Luke's Baptist Hospital
(210) 297-5623

Southeast Baptist Hospital
(210) 297-3610
Baptist Medical Center
111 Dallas Street
San Antonio, TX 78205
FAX: (210) 297-0701
ATTN: Pre-registration

Northeast Baptist Hospital
8811 Village Drive
San Antonio, TX 78217
FAX: (210) 297-0207
ATTN: Pre-registration

St. Luke's Baptist Hospital
7930 Floyd Curl Drive
San Antonio, TX 78229
FAX: (210) 297-0611
ATTN: WC Pre-registration

Southeast Baptist Hospital
4214 East Southcross
San Antonio, TX 78222
FAX: (210} 297-0301
ATTN: Pre-registration

North Central Baptist Hospital
520 Madison Oak Drive
San Antonio, TX 78258
FAX: (210) 297-0401
ATTN: Pre-registration
We look forward to the opportunity of serving you and your family
The Institute for Women's Health
“Our Caring Shows.”
© 1999- Institute For Women's Health
TERMS & CONDITIONS OF USE

All rights reserved   

Website design by Backyard Studios