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STATE OF ILLINOISHEALTH FACILITIES AND SERVICES REVIEW BOARD 525 WEST JEFFERSON ST.SPRINGFIELD, ILLINOIS 62761(217)7823516 FAX: (217) 7854111DOCKET NO: H07BOARD MEETING: November 14, 2017FACILITY

How to fill out 17-036 centegra woodstock add

How to fill out 17-036 centegra woodstock add

1. Start by gathering all the necessary information such as the patient's personal details, insurance information, and medical history.
2. Obtain a copy of the 17-036 Centegra Woodstock Add form.
3. Carefully read through the form and understand each section and its requirements.
4. Begin filling out the form by accurately entering the patient's full name, date of birth, and contact information.
5. Next, provide the necessary insurance details including policy number, group number, and any other relevant information.
6. Proceed to complete the medical history section by accurately documenting any previous illnesses, surgeries, or allergies.
7. If applicable, fill in the section regarding the referring physician and their contact information.
8. Review the completed form for any errors or missing information.
9. Sign and date the form in the designated spaces.
10. Make a copy of the filled-out form for your records before submitting it to the appropriate department or personnel.

Who needs 17-036 centegra woodstock add?

1. The 17-036 Centegra Woodstock Add form is needed by individuals who are seeking medical services at Centegra Woodstock location. This form is used to collect essential information about the patient, their insurance, and medical history. It is typically required for new patients or those who are updating their records.

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What is 17-036 centegra woodstock add?

17-036 Centegra Woodstock Add is a specific administrative form used for reporting and regulatory purposes related to health care services or facilities associated with Centegra Health System in Woodstock.

Who is required to file 17-036 centegra woodstock add?

Entities or individuals who provide specific health care services or operate facilities under Centegra Health System in Woodstock are required to file the 17-036 form.

How to fill out 17-036 centegra woodstock add?

To fill out the 17-036 form, gather required information, such as facility details, service descriptions, and any applicable regulatory information, then complete the form as instructed before submission.

What is the purpose of 17-036 centegra woodstock add?

The purpose of the 17-036 form is to ensure compliance with health regulations and to provide relevant data for assessment, monitoring, and planning of health services in the Woodstock area.

What information must be reported on 17-036 centegra woodstock add?

The report typically requires details on services provided, facility identification, staffing information, and other data pertinent to health service regulations.