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To The One Card In Your Wallet That May Save Your Life!
To apply for
a Global Health Smart Card, simply print out a copy of
this application, complete the requested
information and
be sure to sign your name under Authorization. You can
pay by check or money order.
Mail or bring the completed form with signature and
payment to:
Global Health Smart Card Corporation
18352 Dallas Parkway #136-281
Dallas, Texas 75287
(972) 333-0900 • (214) 601-5806
E-Mail GlobalHSC
info@healthsmartcard.net
PAYER INFORMATION:
(if different from applicant)
Last
Name:
First
Name:
Middle Initial:
Address:
City/State/Zip:
Home Phone:
( )
Work Phone: ( )
Health Smart Card Holder Profile
APPLICANT—PERSONAL INFORMATION
(please
print legibly)
Last
Name:
First
Name:
Middle Initial:
Social Security Number:
Date of Birth
(mo/day/yr):
Sex:
[ ] Male [ ] Female
Street Address:
City/State/Zip:
Home Phone:
( )
Work Phone: ( )
IN CASE OF
EMERGENCY, CONTACT:
Last
Name:
First Name:
Relationship to
Applicant:
Home Phone:
( )
Work Phone: ( )
Cell Phone: ( )
Emergency Note (any
necessary message for emergency personnel):
Last
Name:
First Name:
Relationship to
Applicant:
Home Phone:
( )
Work Phone: ( )
Cell Phone: ( )
Emergency Note (any
necessary message for emergency personnel):
Last
Name:
First Name:
Relationship to
Applicant:
Home Phone:
( )
Work Phone: ( )
Cell Phone: ( )
Emergency Note (any
necessary message for emergency personnel):
MEDICAL
HOSPITAL INFORMATION
Hospital Preference:
Last Hospital Admitted:
Admission Date (mo/day/yr):
Organ Donor? [ ] Yes
[ ] No Living Will? [ ] Yes
[ ] No
Blood Type:
[ ] Check
here if unknown
Was this form verified by
a medical professional? [ ] Yes [ ] No
Medical Note (special
note to all medical personnel):
ALLERGIES
(please
list all known allergies):
Special Allergy Note Area:
MEDICAL
DIAGNOSES / CONDITIONS:
Special Medical Condition Note:
SURGICAL
PROCEDURES
List Surgical Procedure and Date (mo/day/yr):
Special Surgical History Note:
CURRENT
MEDICATIONS
Name of Medication
Strength
How Often Taken
Special Medication Note:
PHYSICIAN /
HEALTH CARE PROVIDER INFORMATION
Name
Specialty
Phone Number
1.
2.
3.
4.
5.
6.
IMMUNIZATIONS
Vaccine Date
Vaccine Date
Vaccine Date
[ ]
Hepatitis A___/___/___ [ ]
Polio ___/___/___
[ ]
Meningococcal ___/___/___
[ ]
Hepatitis A___/___/___ [ ]
Polio ___/___/___
[ ]
Meningococcal
___/___/___
[ ] Hepatitis B___/___/___ [ ]
Polio
___/___/___ [ ]
Zoster ___/___/___
[ ] Hepatitis B___/___/___ [ ]
Polio
___/___/___ [ ]
Rotavirus ___/___/___
[ ] Hepatitis B___/___/___ [ ]
MMR
___/___/___ [ ]
Rotavirus
___/___/___
[ ]
DTaP ___/___/___ [ ]
MMR ___/___/___
[ ]
Rotavirus
___/___/___
[ ] DTaP ___/___/___ [ ]
Measles
___/___/___ [ ]
Vax1
___/___/___
[ ] DTaP ___/___/___ [ ]
Varicella
___/___/___ [ ]
Vax2
___/___/___
[ ] DTaP ___/___/___ [ ]
Influenza
___/___/___ [ ]
Vax3
___/___/___
[ ] DTaP
___/___/___
[ ] Pnuumococcal ___/___/___
[ ] Td
___/___/___
[ ] Pnuumococcal ___/___/___
[ ] Hib
___/___/___
[ ] HPV
___/___/___
[ ] Hib
___/___/___
[ ] HPV
___/___/___
[ ] Hib
___/___/___
[ ] HPV
___/___/___
[ ] TB
Skin Test ___/___/___ [ ] Positive [ ] Negative
Others:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
DTaP = diptheria, tetanus, and
acellular pertusses
Td = tetanus and diptheria
Hib = Haemophilus influenzae type b
Varicella = Chickenpox
MMR = measles, mumps, and rubella
INSURANCE
INFORMATION
Primary
Insurance Co. Name:
Policy
No.:
Group No.:
Insurance Phone: ( )
PreCertification Phone:
( )
Street Address for
Claims:
City/State/Zip:
Name of Guarantor (Policy
Holder):
Guarantor's SSN:
Guarantor's Phone:
( )
Guarantor's
Employer:
Secondary Insurance Co.
Name:
Policy
No.:
Group No.:
Insurance Phone: ( )
SENSITIVE
INFORMATION
If you
have medical history information that you wish
not to include on your Smart Card, but it may be
important in receiving the best care, please check the
appropriate areas below. This will notify medical
personnel that they need to ask you for further
information.
[ ] Other Diagnoses [
] Other Procedures [ ] Other Medications
AUTHORIZATION
The
Health Smart Card service provides you with the use of a
Health Smart Card. By your use of this card, you, the
cardholder, agree to accept responsibility for
accurateness of all information stored on the card's
microchip. When any change is made to the information on
the chip, the cardholder agrees to accept responsibility
of reviewing the information for accuracy.
However,
because of the nature of the electronic equipment
involved and the variety of conditions and environments
in which the Health Smart Card operates, the data on a
card can become unreadable after it is issued. You agree
to assume this risk. You may verify the readability of
your card at participating locations. The Health Smart
Card will be tested automatically whenever changes are
made to the information on the chip. All other
warranties and remedies, expressed or implied, including
all warranties of merchantability and fitness for a
particular purpose are disclaimed. Any unreadable
Health Smart Cards will be replaced at no cost to you.
I
understand and accept the above information.
Signature
Required:
Date Signed:
To apply for a Global
Health Smart Card, simply
print out a copy of this application,
complete the requested information and be sure to sign
your name under Authorization. You can pay by check or
money order. Mail or bring the completed form with
signature and payment to:
GLOBAL HEALTH SMART CARD CORPORATION
18352 Dallas Parkway #136-281 • Dallas, Texas 75287 •
(972) 333-0900 • (214) 601-5806
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