HealthFirst Card Application

First Name:___________________________ MI: ____

Last Name:___________________________________

Address:_____________________________________

City: _____________________________State: _______Zip: ____________


Daytime Phone: ________________________

Evening Phone: ________________________

E-Mail (If Applicable): ______________________


Date of Birth.________________S.S.N. ________-______-___________

Number of Children: ________


Marital Status (Please Circle): Single, Married, Divorced, Separated, Widowed

Primary Insurance (Please Circle): Managed Care Group, Medicare, Group, Other

Policy Number: __________________________________

Name of Insurer: _________________________________

Address of Insurer: _______________________________


MEDICARE NUMBER (IF APPLICABLE):______________________

Primary Care Physician: ______________________________________

Physician’s Phone Number: ______________________


Specialty Physician: __________________________________________

Area of Specialty (OB/GYN,PEDIATRICIAN, ETC.):______________________

Phone Number: ______________________


Employer Name: _______________________________________

Occupation/Title: _______________________________________

I certify that the information listed above is correct and understand that HealthFirst Benefit Card benefits do not begin until the application has been processed and approved. I agree to pay the East Texas Medical Center Regional Healthcare System all charges that are incurred in accordance with the regular policies and charges of any East Texas Medical Center facility when credit is extended to me upon presentation of the HealthFirst Benefit Card.


Signature________________________________________________Date_________________


Please allow approximately 6 weeks for processing and delivery of your HealthFirst Benefit Card. Your benefits will not begin until you receive the card or other written notification that your application has been approved.