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STATE OF ILLINOISHEALTH FACILITIES AND SERVICES REVIEW BOARD 525 WEST JEFFERSON ST.DOCKET NO: H10SPRINGFIELD,ILLINOIS 62761BOARD MEETING: February 16, 2016(217)7823516 FAX: (217) 7854111PROJECT NO: 15058PROJECT
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01
Obtain Form 12-15-058--standing-emergency-center from the appropriate authority or website
02
Fill out the patient's personal information including name, date of birth, address, and contact information
03
Provide details of the emergency center visit, including date and time of arrival
04
Describe the medical condition or reason for the visit in detail
05
Include any relevant medical history or pre-existing conditions
06
Provide information on any medications being taken or allergies
07
Sign and date the form as required

Who needs 12-15-058--standing-emergency-center?

01
Individuals who have visited a standing emergency center and need to provide documentation for insurance purposes
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Medical facilities that require official records of patient visits for billing and compliance purposes
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12-15-058--standing-emergency-center is a form used for reporting standing emergency center information.
Standing emergency centers are required to file 12-15-058--standing-emergency-center.
12-15-058--standing-emergency-center must be filled out with accurate information about the standing emergency center.
The purpose of 12-15-058--standing-emergency-center is to provide important information about standing emergency centers.
12-15-058--standing-emergency-center must include information such as location, services provided, and contact information of the standing emergency center.
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