Registration form please fill out "bold" highlighted areas in black ink

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Date conversion05.05.2018
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Please fill out “BOLD” highlighted areas in black ink

Registration Eligibility Data

Last name First Name MI

SSN: 20/______________ Branch of Service:_USN__________ Active Duty? __Y___
Date of Birth:___________ Duty Station:___USNA / N00161_____________________________
Duty Address:_250_____WOOD___RD_________________ANNAPOLIS________MD_______21402_

Number Street City State Zip

Duty Phone: __3-1249___ Rank: ___MIDN 4/C_

Patient Data

Patient Sex: M F Patient DOB: _________ Patient FMP: _20___

(FMP is explained on back)

Record Location: _BHC BANCROFT_________ Religion: ________________________
Race: (circle one) Asian-pacific Islander / Black / Other / Unknown / western Hemisphere Indians / White

Ethnic Origin: (circle one) Filipino / Hispanic / Other / Other Asian-Pacific Islander / South East Asian / Unknown
Home Address:______________________________________________________________________________

Number Street City State Zip

Home Phone: ____________________
Allergies? Y N If Y please list them: __________________________________________________

Emergency Data

In case of Emergency, Contact: ___________________________ Phone # : _______________
Address: ______________________________________________________________________

Number Street City State Zip

Primary Next of Kin: _____________________________ Relationship: _________________
Address: __________________________________________________________________________

Number Street City State Zip

Phone #: _____________

NHCLA 6150/24

Continued on back

Do you have any insurance, other than Tri-Care?
If Yes, please list name of company and the policy number________________________________

I certify that the above information is true to the best of my knowledge. Falsification of information is covered by 18 U.S. Code, section 1001 which provides for a maximum fine of $10,000 or imprisonment of five years, or both. I hereby authorize and request that the proceeds on any and all benefits be paid directly to the facility of the uniformed service for hospitalization or outpatient services provided m and/or my dependents.

Patient Signature: ________________________________________ Date: __________

FMP is the Family Member Prefix:

The FMP is used to signify the relationship between a patient and sponsor.

For Example:

20—Active Duty or Retiree

30—Sponsor first spouse

31—Sponsor second spouse

01—First born child

02—Second born child


CHCS: _________ LABEL MADE: _____________ RECORD MADE: ____________

This document may contain information covered under the Privacy Act, 5 USC 552(a), and/or the Health Insurance Portability and Accountability Act (PL104-191) and its various implementing regulations and must be protected in accordance with those provisions. Healthcare information is personal and sensitive and must be treated accordingly. If this correspondence contains healthcare information it is being provided to you after appropriate authorization from the patient or under circumstances that don't require patient authorization. You, the recipient, are obligated to maintain it in a safe, secure and confidential manner. Redisclosure without additional patient consent or as permitted by law is prohibited. Unauthorized redisclosure or failure to maintain confidentiality subjects you to application of appropriate sanction. If you have received this correspondence in error, please notify the sender and once and destroy any copies you have made.

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