Hospital Admission Letter
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PERSONAL AND ADMINISTRATION DETAILS Mr Surname (family name): First name(s): Date of birth: Mrs Ms Miss Mstr Dr Preferred name: dd / mm / yyyy Gender: Male Female NHI: Residential address: Postal address: Email address: Telephone: (Home) New Zealand resident: Yes (Business) (Mobile) No Ethnicity: European / Maori / Pacific Island / Asian / Middle Eastern / Latin American / African / Other General Practitioner (Name): ( Please circle one or more) Telephone: Medical Centre: NEXT OF KIN/CONTACT PERSON Name: Relationship to patient: Address: Telephone: (Home) (Business) (Mobile) PAYMENT DETAILS How will your procedure be paid for Tick and complete as many as applies: Health insurance (personal expenses such as telephone calls are excluded) Name of Insurer: Insurance Plan Name: Have you obtained “prior approval” for payment Yes No ACC (personal expenses such as telephone calls are excluded) Membership No: Approval No: (Bring your prior approval letter) DHB (personal expenses such as telephone calls are excluded) Paid personally If you are paying for the procedure yourself, you may be asked to pay an estimated deposit 3-5 days before admission..
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