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online pre-registration form

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

Upon your arrival at the hospital, please stop at the Patient Registration area to complete the registration process.

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.
This is a secure page.
PRE-REGISTRATION INFORMATION
 What is your surgery/c-section date or estimated maternity due date? *
 
IMPORTANT: Your pre-registration must be received at least one business day (24hours) prior to your registration/surgery date.

If you are within one business day of your visit, please complete the registration at the hospital.
 What procedure are you going to receive?*
Surgery
Maternity/C-Section
 What is your admitting doctor's name? *
 What is your family doctor's name?*
 
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 *
(format: MM/DD/YYYY)
 Street Address *

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

 Other
 Specific Place of Worship Attend
 Marital Status
 Employment Status *
 Patient's Employer *
(If not employed, put "NONE".)
 Address
 Job Title
 Work Phone *
(Enter 999 if no work number)
( ) -
 
CONTACT INFORMATION (Emergency Contact)
 Next of Kin
(list someone who lives with you or list someone that is responsible in case of emergency) *

   Relationship *
   Address
   Phone No.*
()-
 Additional Person to Notify (second emergency contact)
   Relationship
   Address
 

 Phone No.
()-

 
FINANCIAL RESPONSIBILITY
(If insured, name of person who holds insurance)
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 *
--
  Date of Birth *
(format: MM/DD/YYYY)
 Employer *
(If not employed, put "NONE".)
 Address *
(If not employed, put "NONE".)
 Phone number where you can be reached at work *
(Enter 999 if no work number.)
() -
 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
 Are you receiving Social Security checks?
Yes No
 
INSURANCE
 Do you have insurance? 
Yes No
   Method of Payment
 Insurance Company Name
     Address
(claims address listed on card)
     Phone (Customer Service Number)
()-
     Policy Holder (Whose name is the insurance in?)
     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 (Secondary insurance)
     Address
(claims address listed on card)
     Phone (Customer Service Number)
())
     Policy Holder (Whose name is the insurance in?)
     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?
BABY'S INSURANCE

 WILL BABY BE COVERED UNDER INSURANCE?
Yes No
(If yes, have you notified the insurance company?)

   Method of Payment
   Insurance Company Name
   Address
   Phone (Customer Service Number)
( ) -
   Policy Holder (Whose name is the insurance in?)
   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
 
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 ALL INSURANCE CARDS AND DRIVER’S LICENSE WITH YOU TO PATIENT REGISTRATION WHEN YOU ARRIVE.

If you have questions regarding insurance coverage or payment options, please contact our financial counselor at 812-842-4240.

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