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COVID-19 Vaccine Registration Form

What to Bring

What to Bring for Registration

It is imperative for complete and accurate billing that we receive proper patient identification and current insurance information at each registration. The below items may or may not be necessary, depending on your individual situation. It is vitally important that you bring everything necessary with you.

Picture identification

Insurance card, including the insurer's name, address, date of birth and the patient's policy number

Social security number for patient and spouse
Cash, check, or major credit card (Visa, MasterCard, or American Express) to pay for services not covered by insurance.

Your employer's name, address, and phone number - if you are covered by traditional insurance or managed care (HMO or PPO) provided by that employer

Your spouse's employer's name, address, and phone number - if you are covered by traditional insurance or managed care (HMO or PPO) provided by your spouse's employer

Managed Care Referral Authorization - if you are covered by an HMO or POS plan and it is required

Medicare or Medicaid card, plus the date of your spouse's retirement if that applies to you

Advance Directive (living will)

Name, address, and phone number of your referring physician if you were referred here.

Advance Directive

You have the right to make informed decisions about your healthcare, including the right to accept or refuse treatment offered to you and the right to formulate advance directives. Accordingly, you may provide directions to the hospital, in advance, about your wishes for healthcare decisions should the time come when you cannot communicate your wishes to others.

Federal regulations require hospital personnel to inquire as to the presence of an Advance Directive. This includes a living will or durable power of attorney with a healthcare clause. Information on Advance Directives is provided to every patient upon admission. If you already have an advance directive such as a living will or durable power of attorney for healthcare, please provide the staff with a copy of it at the time of admission. For your assistance, Chris Kovarek, Social Worker, is available to answer any of your questions.

What to Bring for Your In-Patient Stay

To help assure a comfortable hospital stay, the items you may wish to bring with you include:

Personal toiletries, such as shampoo, toothpaste, and toothbrush

Bathrobe and slippers or socks

Medications you take on a regular basis. Please write your name on the containers and inform your nurse. Be sure to take these medications home with you.

Glasses, dentures, hearing aid, or other assistive devices you may need. Please ask the nurse for a container to protect these items. Please label these and other personal items with your name, if possible.

Any instructions your physician may have provided

Cash to purchase a magazine, snack, and/or debit card for long distance calls (local calls are free).

What Not to Bring

As you probably know, hospitals are busy places. It can be difficult to keep track of personal items here. We are sorry that Memorial Medical Center cannot be responsible for your personal items, and ask that you NOT bring the following items:

Jewelry or other valuables

A lot of money or extra credit cards

Hair dryer, electric shaver, or other electrical appliances (If you need assistance shaving, ask your nurse or another patient care staff member.)

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