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Decatur General Hospital

Patient Pre-registration Application

Thank you for choosing Decatur Morgan Hospital for your healthcare needs.
Please take a few minutes to complete the pre-registration form below. Please allow 2-3 business days prior to your scheduled service for your pre-registration to be completed.
* Patient Full Name
First Name, Middle Name, Last Name
* Primary Physician
  Referring Physician
Please list the physician that referred you to DGH for your test. If none, please state not applicable.
 
Did the Referring Physician provide you with a copy of your orders? If so please bring with you on the date of your Procedure/Test.
yes     no    
  Today's Date
  Procedure/Test
Please list the procedure or test for example: x-ray, surgery, ultrasound
  Procedure Date/Test Date/Due Date
Please list non-scheduled for Lab or any procedure without a scheduled date.
* Street Address
Full Street Address or P.O. Box
* City
  County
* State
* Zip Code
* Home Telephone Number
Area Code and 7 Digit Number
  Cellular Phone
Please provide your cellular phone number if applicable.
  Best time of day to reach you: Morning     Afternoon     Both    
  Marital Status Single     Married     Divorced     Widowed    
* Date of Birth
  Sex Male     Female    
  Race Black     White     Asian     Indian     Hispanic     Other    
* Social Security Number
Nine Digit Social Security Number
  Religion
  Are You Employed? Yes     No    
  Employer's Name
If you are employed please list your major employer's business name. If not employed, please list retired, disabled, not employed, etc.
  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
If applicable
Insurance Information
* When Paying Healthcare Bills...How Do You Plan To Pay? Insurance     Cash     Medicaid     Medicare    
  Primary Insurance Provider
Example: BCBS, United Health Care, Aetna etc.
  Policy Number
Please list as it appears on your insurance card.
  Group Number
Please list as it appears on your insurance card.
  Effective Date of Coverage
Should be listed on your insurance card.
  Secondary Insurance Provider
Example: BCBS, United Health Care etc.
  Policy Number
Please list as it appears on your insurance card.
  Group Number
Please list as it appears on your insurance card.
  Effective Date of Coverage
Should be listed on your insurance card.
  Is patient above the responsible party? yes     no    
Responsible Party Information
Please fill out the information below if the patient listed above Is NOT The Responsible 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
  Social Security Number
Nine Digit 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
  Person To Notify In Case Of An Emergency
Please Type In Full Name, Relationship, Address, Area Code & Telephone Number
  Alternate Contact
Please list someone outside your home in case we need to reach you.