Get Ozarks Community Hospital Patient Information Please Fill Out Form Completely 2020-2025

The Ozarks Community Hospital Patient Information form is essential for providing accurate and comprehensive information for your healthcare needs. This guide will help you navigate the form efficiently, ensuring that all required fields are filled out completely and correctly.

Follow the steps to complete your patient information form online.

1. Click the ‘Get Form’ button to access the patient information form online.
2. Begin by entering your account number at the top of the form. If you do not have one, leave this blank.
3. Fill in your name, including your last name, first name, and middle initial, along with your maiden name where applicable.
4. Provide your date of birth, ensuring the format is month/day/year.
5. Enter your complete address, including any PO Box or street address, city, state, zip code, and county.
6. Indicate your home, work, and cell phone numbers, as well as the name and address of your employer.
7. Select your sex and marital status, and fill in your Social Security number for identification.
8. Provide your email address; this is for internal use only.
9. Indicate whether you smoke and provide details about your referring physician and primary care physician.
10. Answer questions regarding your chief complaint or current medical problem, including whether it was due to an accident and provide details if applicable.
11. Fill in information about any surgeries you've had, including dates and reasons.
12. Complete the emergency contact section with the name, relationship, date of birth, and phone number of the contact.
13. If you are filling out the form for a minor, provide information about the spouse or responsible party, including their name and contact details.
14. Input the insured's information, whether the insured is the same as the patient or not, and fill in primary and secondary insurance details as needed.
15. Review all sections thoroughly for accuracy, ensuring all necessary fields are completed.
16. Once all information is filled out, save your changes, and choose to download, print, or share the form as required.

Complete your Ozarks Community Hospital Patient Information form online today to ensure a smooth healthcare experience.