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Health Financial Systems FRANCISCAN HEALTH HAMMOND In Lieu of Form CMS255210 This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim FORM APPROVED payments
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Start by obtaining the necessary forms from the admissions desk at Franciscan Health Hammond.
02
Fill out your personal information in the designated fields, including your full name, date of birth, address, and contact information.
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Provide your insurance information, including the name of your insurance provider, policy number, and any other relevant details.
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Answer the medical history questions accurately, providing information about any pre-existing conditions, allergies, or medications you are currently taking.
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Specify the reason for your visit and the department you need to see.
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If applicable, provide details about your primary care physician and any referral information.
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Sign and date the form to certify that the information provided is accurate and complete.
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Submit the filled-out form to the admissions desk or the appropriate department at Franciscan Health Hammond.

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Franciscan Health Hammond is needed by individuals who require medical care, including diagnosis, treatment, and ongoing healthcare services.
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It is suitable for individuals of all ages who seek quality healthcare and want access to a wide range of specialists and medical facilities.
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People who live in the vicinity of Hammond, Indiana and surrounding areas can benefit from the services provided by Franciscan Health Hammond.
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Franciscan Health Hammond is a hospital located in Hammond, Indiana.
The hospital administration or designated personnel are required to file Franciscan Health Hammond.
The form for Franciscan Health Hammond can be filled out online or submitted in person at the hospital.
The purpose of Franciscan Health Hammond is to report key healthcare data and statistics of the hospital.
The information reported on Franciscan Health Hammond includes patient demographics, medical procedures performed, and hospital revenue.
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