Healthy Lifestyles Membership Application
 

Please Note: Submitting this form does not finalize membership. Payment is due prior to becoming a member. Please call HealthFinder at (504) 456-5000 to arrange for payment.

 
Applicant's Name: *
Applicant's Sex: *
Applicant's Birthdate: * Ex:1975
   
Co-Applicant's Name:
Co-Applicant's Sex: Male Female
Co-Applicant's Birthdate: Ex:1975
Relationship to Member:
   
Address: *
City, State, Zip Code: *
Phone Number: *
Email Address: *
Marital Status:
   
Lifetime membership fee of $50 for first qualifying member, $25 for second member in the same household.
   

Notice of Privacy Practices: East Jefferson General Hospital offers assistance to its Healthy Lifestyles members with processing their East Jefferson General Hospital bills. Staff members are EJGH employees and serve in an adjunct capacity to the hospital's patient finance department. If you use the billing assistance service, Healthy Lifestyles staff will have access to your medical billing records contained in the EJGH records systems. Federal privacy laws will prevent Healthy Lifestyles from assisting you with processing your bills with any other healthcare organization. EJGH Healthy Lifestyles maintains a general membership listing. This listing does not contain any medical information on members. The list is used solely for administration of the Healthy Lifestyles program and is not used or disclosed for any other purposes.

East Jefferson General Hospital reserves the right to alter or discontinue this program. Members must be 21 years of age.

   
Please Note: Submitting this form does not finalize membership. Payment is due prior to becoming a member. Please call HealthFinder at (504) 456-5000 to arrange for payment.