City	State	Zip

Daytime Phone
( ) - -

E-mail Address

Location
Please select the Advocate hospital at which you’d like to participate in Senior Programs:
Select a location Bethany Hospital Christ Medical Center Good Samaritan Hospital Good Shepherd Hospital Lutheran General Hospital Illinois Masonic Medical Center South Suburban Hospital Trinity Hospital

Marital Status
Married	Single
Divorced	Widowed
Gender
Male	Female

Date of Birth
Month January February March April May June July August September October November December Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99

Insurance
(check all that apply)

	Medicare A
	Medicare B
	Your Medicare Number
	Medicare HMO
	Name of Plan
	Medicare Supplemental Insurance Plan
	Name of Plan
	Policy Number
	Medicaid
	Employer/Other Insurance
	Name of Plan Policy Number

Medical Information

Do you have a physician?
Yes	No

Physician’s Name


Physician’s Phone
( ) - -

By checking this box, I state my understanding that the Senior Advocate program offered by Advocate Health Care is not an insurance policy.