Get Boca 12109 Registration Brochure.indd

Filling out the BOCA 12109 Registration Brochure is an essential step in preparing for your scheduled birth at Boca Raton Community Hospital. This guide provides clear instructions to help you complete the form online with ease.

Follow the steps to accurately complete the registration form online.

1. Click the ‘Get Form’ button to access the registration brochure in the online editor.
2. Begin with the demographic information section. Enter the patient's name, including the last name, first name, and middle name.
3. Provide the patient's social security number and expected due date.
4. Fill out the attending physician’s name and indicate whether the patient has received tests or services at BRCH before, specifying under what name.
5. Record the patient's date of birth by entering the month, day, and year, along with the state of birth.
6. Declare the marital status by selecting from married, single, widowed, divorced, or separated.
7. Input the current address, including city, state, zip code, and home telephone number.
8. Indicate the patient's race.
9. Provide the patient’s employer details, including the address, city, state, zip, telephone number, and occupation.
10. Answer whether healthcare choices have been made through an advance directive. Indicate the religious preference and the name of the church or synagogue.
11. Fill in the spouse's name, date of birth, social security number, work number, employer, and occupation, if applicable.
12. Specify an emergency notification name along with their telephone number, relationship to the patient, and their address, home, and work telephone numbers.
13. Answer questions regarding diabetes diagnosis, medical allergies, organ donor status, and indicate the name of the pediatrician.
14. Fill out the primary insurance information, including the insurance company name, claims address, employer name (if applicable), subscriber details, and policy number.
15. Complete the secondary insurance information similarly, if applicable.
16. Review all provided information for accuracy, then save your changes, and choose to download, print, or share the completed form.

Complete your registration form online now to ensure a smooth admission process.