Patient Name:
* First:
* Last:
Address:
Street:
Apt/Bldg:
City:
State/Zip:
* Date of Birth:
Home Phone:
Contact me:
E-Mail Address:
INSURANCE AND FINANCIAL RESPONSIBILITY: If you have any questions about your insurance coverage, benefits or the cost of your care, you may contact our patient service representatives as they can best answer your questions. Upon admission, arrangements will be made to have your insurance benefits assigned to Hartford Hospital. Hartford Hospital participates in and accepts most major payers.
Note: If you would like a response to your inquiry, please be sure to include a postal address, e-mail address, or phone number. In addition, please allow 3-5 business days for a response as your inquiry may require research.
