VIP Program Application

Good Samaritan Hospital Gold Medical Access Card Application

Patient Information

Last Name
First Name
Middle Initial
Gender
Birth Date
Marital Status
Street Address
City
State
Zip Code
Ethnicity (Optional)
Social Security Number (If you prefer, we can call you for your SSN instead)
--
Main Phone
Other Phone
Email
Occupation
Employer Name
Employer Address
Employer Phone
Advance Directives
Primary Language Spoken

Next of kin or friend in case of an emergency

Last Name
First Name
Relationship
Contact Phone
Street Address
City
State
Zip Code
GSH Primary Care Physician Name
Have you seen this physician before?

Insurance Information

Primary

Insurance Name
Phone # to verify coverage
Policy ID #
Subscriber Name
Subscriber Relationship
Subscriber SSN
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DOB

Secondary

Insurance Name
Phone # to verify coverage
Policy ID #
Subscriber Name
Subscriber Relationship
Subscriber SSN
--
DOB

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Dedicated to Providing the Best Care Possible

At Good Samaritan Hospital Los Angeles, we have the expertise and facilities you would expect at a state-of-the-art medical facility.

  • 408

    Beds

  • 18

    Surgical Suites

  • 625

    Medical Staff Members