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pre-admission registration

 

Thank you for submitting your registration information prior to your upcoming visit.

Upon your arrival at the hospital, the registration process will be completed when you arrive at the Patient Registration area.

NOTE: Here are some "tips" to keep in mind when filling out the form:

  • You may need to refer to your insurance card(s) to answer some of the questions. If you have insurance, please have your insurance card(s) available.
  • The patient registration staff will contact you if your information needs clarification or is incomplete.
  • For date fields, use the mm/dd/yyyy format.
  • For phone number fields, use the 999-999-9999 or 9999999999 formats.
  • Click on the ? for help in each section.
  • * indicates a required field. It cannot be blank.
PRE-REGISTRATION INFORMATION
 When is your registration/surgery date? *
 
If you would prefer to pre-register by phone, please call one of the pre-registration numbers.
 What time is your registration/surgery? *
am pm
 What is your diagnosis?*
 
 What procedure are you going to receive?*
 
 At which Deaconess facility are you being admitted?
Deaconess Main Campus Deaconess Gateway
 What is your admitting doctor's name? *
 What is your family doctor's name?*
 What is your referring doctor's name? *
 Will you be arriving by ambulance?
yes  no
 Have you been a patient at Deaconess Hospital before? *
yes no
 If so, What is the admitting date of your previous stay?
 Have you been a patient in nursing home in last 60 days?
yes no  If so, When & Where?
 Have you had other hospital admissions in last 60 days?
yes no
 Room Preference
Private Semi
 Helping Hand Member
yes no
 
PATIENT INFORMATION
 Patient's Last Name *
Patient's First Name *
 Middle Initial
 Known as
 E-mail Address *
 Race
 Sex *
Male Female
 Age
 Date of Birth *
 Street Address *

 County *
 City *
 State *
 ZIP Code*
 Social Security *
 Patient's Home Phone *
( ) -
 Religious Preference

 Other
 Specific Place of Worship Attended
 Marital Status
 Employment Status *
 Patient's Employer *
 Address
 Job Title
 Work Phone *
( ) -
 
CONTACT INFORMATION
 Next of Kin (parent's name if child) *
   Relationship *
   Address
   Phone No.*
()-
 Additional Person to Notify
   Relationship
   Address
 

 Phone No.
()-

 
FINANCIAL RESPONSIBILITY
Check to copy patient information to financial section  
 Name of Person Financially Responsible for hospital bill
 Last Name* 
 First Name* 
Middle Initial
 Relationship to Patient. *
 Address *
 Phone No.*
() -
 Social Security *
 Employer *
 Address *
 Phone number where you can be reached at work *
() -
 Marital Status of Responsible Party
 Spouse's Name
 Phone number if different
() -
 Employer
 
INSURANCE INFORMATION
MEDICARE/MEDICAID
 Are you covered by Medicare? 
Yes No
If yes,   Medicare number
   Part A Hospital Effective Date
 Part B Medical Effective Date
   Name as it appears on your card
 Are you covered by Medicaid?
Yes No
If yes,  Medicaid Number
   Effective Date
   State
   Recipient's Name
 
OTHER INSURANCE
 No Insurance/Self Pay 
Yes No
   Method of Payment
 Insurance Company Name
     Address
     Phone
()-
     Policy Holder
     Policy Number
     Policy Holder's Social Security Number
Policy Holder's Date of Birth
     Policy Holder's Address
     City
 State
 ZIP Code
     Individual or Group
Individual Group
    If Group,  Name of Employer
       Group Number
 Insurance Company Name
     Address
     Phone
())
     Policy Holder
     Policy Number
     Policy Holder's Social Security Number
Policy Holder's Date of Birth
     Policy Holder's Address
     City
 State
 ZIP Code
     Individual or Group
Individual Group
    If Group  Name of Employer
       Group Number
 Any Other Insurance?
 
 
ACCIDENT/ILLNESS INFORMATION
 Type of Accident/Illness/
 Location (if Accident)
 Date of Accident/Illness
 Time of Accident/Illness
 
FOLLOW-UP

Upon receipt of this completed pre-registration form, a representative will verify your insurance and then follow up with you regarding any co-insurance payment that may be due at the time of service.

How do you prefer we contact you for the follow up?

  email 1 email address:
1: the email reply is not a secure form of communication. more information
  phone phone number:
( )-
Please bring your Medicare, Medicaid, or other insurance cards with you to Patient Registration when you arrive.
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