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Thank you for choosing El Campo Memorial Hospital for your next medical visit. By completing this pre-registration form, you can receive peace of mind that we have your medical information for your upcoming services.
To pre-register for Mid Coast Medical Clinic, please click the following link: http://www.ecmh.org/getpage.php?name=mcmc. |
Complete the following information as accurately as possible. This form should take 4 or 5 minutes to complete. To submit your information simply click the "Submit Form" button to complete your pre-registration process. (*) Required information is necessary. |
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Today's Date (Required) |
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Date of Birth (Required) |
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Last 4 Digits of Social Security Number Last 4 Digits of Social Security Number |
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Patient Full Name First Name, Middle Initial, Last Name (Required) |
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Street Address or P.O. Box (Required) |
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City (Required) |
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County (Required) |
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State (Required) |
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Zip Code 5 Digit Zip Code (Required) |
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Home Phone Number Area Code and 7 Digit Number (Required) |
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Cell Phone Number Area Code and 7 Digit Number |
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Marital Status (Required) |
Single Married Divorced Other |
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Sex (Required) |
Male Female |
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Race (Required) |
African American Caucasian Asian Hispanic Other |
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Religion (Required) |
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Employment Status |
Employed Unemployed |
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Employer's Name If you are employed please list your major employer's business name. |
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Employer's Street Address |
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City |
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State |
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Zip Code 5 Digit Zip Code |
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Employer Phone Number Area Code Plus 7 Digit Number |
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Retirement Date Fill In This Field Only If You Expect To Retire. |
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How Do You Plan To Pay? (Required) |
Cash Check Credit Card |
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Responsible Party Information Fill Out Below If The Patient Is Not The Resonsible Party |
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Person Responsible For Bill |
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Date of Birth |
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Street Address or P.O. Box |
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City |
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State |
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Zip Code 5 Digit Zip Code |
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Home Phone Number Area Code and 7 Digit Number |
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Cell Phone Number Area Code and 7 Digit Number |
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Sex |
Male Female |
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Relationship To Patient |
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Last 4 Digits of Social Security Number Last 4 Digits of Social Security Number |
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Employer's Name If you are employed please list your major employer's business name. |
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Employer's Street Address |
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City |
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State |
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Zip 5 Digit Zip Code |
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Employer Phone Number Area Code Plus 7 Digit Number |
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Person To Notify In Case Of An Emergency Please Type In Full Name, Relationship, Area Code & Telephone Number (Required) |
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May we discuss personal information with this person? |
Yes No |
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Health Care Coverage (Required) |
Insurance Medicare Medicaid Self Pay (Payment Arrangement Contract) |
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Policy Holder's Name |
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Policy Holder's Date of Birth |
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Insurance Name Name of Primary, Secondary and Third Insurance if applicable. |
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Policy Information Policy/Identification Number and Group Number of Primary, Secondary, and Third Insurance if applicable. |
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Medicare Identification Number 9 Digit Number and Letter |
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Type Of Medicare Coverage In Patient, Out Patient, Or Both |
Type A Type B Both |
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Medicare Supplement Name |
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Medicare Supplement Identification Number This number may contain letters. |
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Medicaid Manage Care Please Note MMC is NOT in Network with Amerigroup or Evercare All Services Will Require Prior Authorization |
Traditional Driscoll Superior Amerigroup Evercare Other |
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Medicaid Identification Number 9 Digit Number (CHIPS ID Number may contain a letter) |
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Financial Assistantance Program Memorial Medical Center offers financial assistance for qualified Calhoun County residents. |
Charity Program Indigent Program |
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Type Of Service (Required) |
Lab X-Ray Cardio Surgery Physical Therapy Other |
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Appointment Date Please provide your scheduled appointment date if available. |
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Ordering Physician Doctor who signed the Order (Required) |
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Primary Physician Family Physician (Required) |
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