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Allen Parish Hospital

Patient Pre-registration Application for Lab Services Only

Pre-registration must be submitted at least 24 hours before patient visit and for your registration to be complete you will need to sign in with the Out Patient Department. Make sure to bring your Drivers License, Insurance Cards, and a Valid Physician Order written within 30 days of service.
Please make sure all your legal information is entered correctly and complete the following information.
This process should take 4 or 5 minutes to complete.
* Submit Date
* Expected Date of Service
* Patient Full Name
First Name, Middle Initial, Last Name
* Date of Birth
* Last 4 Digits of Social Security Number
Last 4 Digits of Social Security Number
* Mailing Address
Please list your preferred mailing address
* City
* State
* Zip Code
* County
* Telephone
Please list your preferred number with the Area Code
* Marital Status Single     Married     Divorced     Widowed    
* Sex Male     Female    
* Race Black     White     Asian     Indian    
* Religion
* Primary Physician
* Person To Notify In Case Of An Emergency
Please Type In Full Name, Relationship, Address, Area Code & Telephone Number
  Insurance or Medicare/Medicaid Numbers
We Need Your Basic Health Insurance Information. Please Include Your Primary and Secondary Insurance ID Numbers as well as the Group Numbers as provided on the card. Please Also List Your Effective Date of Coverage. Bring Insurance Cards at time of visit.
* Are You Employed? Yes     No    
  Employer's Name
If you are employed please list your major employer's business name.
  Employer's Street Address
  City
  State
  Zip Code
Five Digit Zip Code
  Employer Phone Number
Area Code Plus 7 Digit Number
  Type of Position Full Time     Part Time    
  Occupation
  Retirement Date
Fill In This Field Only If You Expect To Retire.
* When Paying Healthcare Bills...How Do You Plan To Pay? Insurance     Cash     Medicaid     Medicare    
  Responsible Party Information
Fill Out Below If The Patient Is Not The Resonsible Party
  Person Responsible For Bill
  Date of Birth
  Street Address or P.O. Box
  City
  State
  Zip Code
Five Digit Zip Code
  Telephone
Area Code and 7 Digit Number
  Sex Male     Female    
  Relationship To Patient
  Last 4 Digits of Social Security Number
Last 4 Digits of Social Security Number
  Employer's Name
If you are employed please list your major employer's business name.
  Employer's Street Address
  City
  State
  Zip
Five Digit Zip Code
  Employer Phone Number
Area Code Plus 7 Digit Number
  Type of Position Full Time     Part Time    
  Responsible Party's Occupation