Health Smart Card Application

Health Smart Card
Application

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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

IMMUNIZATIONS
Vaccine Date Vaccine Date Vaccine Date

[ ] Hepatitis A___/___/___ [ ] DTaP ___/___/___ [ ] MMR ___/___/___

[   ] Hepatitis A___/___/___       [   ] Td    ___/___/___        [   ] MMR         ___/___/___

[   ] Hepatitis B___/___/___         [   ] Hib   ___/___/___         [   ] Measles     ___/___/___

[   ] Hepatitis B___/___/___        [   ] Hib   ___/___/___        [   ] Varicella     ___/___/___

[   ] Hepatitis B___/___/___        [   ] Hib   ___/___/___        [   ] Influenza    ___/___/___

[   ] DTaP         ___/___/___         [   ] Polio ___/___/___        [   ]Pneumovax ___/___/___

[   ] DTaP         ___/___/___          [   ] Polio ___/___/___

[   ] DTaP         ___/___/___          [   ] Polio ___/___/___

[   ] DTaP         ___/___/___          [   ] Polio ___/___/___

[ ] TB Skin Test ___/___/___ [ ] Positive [ ] Negative

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

To print this form — click the printer icon above
or, from the File menu choose Print.