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03×14/2014 PHILADELPHIA COUNTY NORTH COMMONWEALTH OF PA Workers' Compensation Program: Designated Health Care Providers NOTICE TO EMPLOYEES IN CASE OF WORK-RELATED INJURIES If you suffer a work-related

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How to fill out Jeanes Hospital - homsinc:

1. Start by accessing the Jeanes Hospital - homsinc form online or obtain a physical copy from the hospital.
2. Read the instructions carefully to understand the information and requirements necessary for completion.
3. Begin filling out the form by providing your personal details such as your full name, address, contact information, and date of birth.
4. If applicable, include the name and contact information of your primary healthcare provider.
5. Next, fill in your insurance details, including the name of your insurance provider, policy number, and any additional information required.
6. Provide information about your medical history, including any previous or ongoing health conditions, medications, or surgeries.
7. If the form asks for emergency contact information, make sure to provide the names and contact details of the individuals you would like to be reached in case of emergency.
8. Carefully review the completed form for any errors or omissions, ensuring all information is accurate and up-to-date.
9. Sign and date the form as required, indicating your consent and agreement with the provided information.
10. Finally, submit the filled-out form to the designated recipient, whether it be a hospital staff member, an online portal, or through mail, depending on the specific instructions provided.

Who needs Jeanes Hospital - homsinc:

1. Individuals who are seeking medical treatment or services from Jeanes Hospital.
2. Patients who have been referred to Jeanes Hospital by their primary healthcare providers.
3. Individuals who require specialized medical care that Jeanes Hospital offers, such as surgeries, diagnostic tests, or consultations with specialists.

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