Health and Human Services

Emergency Encounter

Emergency Room Information

Submitter Name

This is a required field.

Emergency Room Location

This is a required field.

Emergency Room Phone

This is a required field.

Date of Service

This is a required field.

Must be in the format MM/DD/YYYY.

Member Information

Member First Name

This is a required field.

Member Last Name

This is a required field.

Member Number

This is a required field.

Member Date of Birth

This is a required field.

Must be in the format MM/DD/YYYY.

Member Phone Number

This is a required field.

Member Address

This is a required field.

City

This is a required field.

State

This is a required field.

ZIP

This is a required field.