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El Campo Memorial Hospital

Hospital Patient Pre-Registration Form

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.
* Today's Date
(Required)
* Date of Birth
(Required)
* Last 4 Digits of Social Security Number
Last 4 Digits of Social Security Number
* Patient Full Name
First Name, Middle Initial, Last Name (Required)
* Street Address or P.O. Box
(Required)
* City
(Required)
* County
(Required)
* State
(Required)
* Zip Code
5 Digit Zip Code (Required)
* Home Phone Number
Area Code and 7 Digit Number (Required)
  Cell Phone Number
Area Code and 7 Digit Number
* Marital Status
(Required)
Single     Married     Divorced     Other    
* Sex
(Required)
Male     Female    
* Race
(Required)
African American     Caucasian     Asian     Hispanic     Other    
* Religion
(Required)
  Employment Status Employed     Unemployed    
  Employer's Name
If you are employed please list your major employer's business name.
  Employer's Street Address
  City
  State
  Zip Code
5 Digit Zip Code
  Employer Phone Number
Area Code Plus 7 Digit Number
  Retirement Date
Fill In This Field Only If You Expect To Retire.
* How Do You Plan To Pay?
(Required)
Cash     Check     Credit Card    
  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
5 Digit Zip Code
  Home Phone Number
Area Code and 7 Digit Number
  Cell Phone Number
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
5 Digit Zip Code
  Employer Phone Number
Area Code Plus 7 Digit Number
* Person To Notify In Case Of An Emergency
Please Type In Full Name, Relationship, Area Code & Telephone Number (Required)
* May we discuss personal information with this person? Yes     No    
* Health Care Coverage
(Required)
Insurance     Medicare     Medicaid     Self Pay (Payment Arrangement Contract)    
  Policy Holder's Name
  Policy Holder's Date of Birth
  Insurance Name
Name of Primary, Secondary and Third Insurance if applicable.
  Policy Information
Policy/Identification Number and Group Number of Primary, Secondary, and Third Insurance if applicable.
  Medicare Identification Number
9 Digit Number and Letter
  Type Of Medicare Coverage
In Patient, Out Patient, Or Both
Type A     Type B     Both    
  Medicare Supplement Name
  Medicare Supplement Identification Number
This number may contain letters.
  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    
  Medicaid Identification Number
9 Digit Number (CHIPS ID Number may contain a letter)
  Financial Assistantance Program
Memorial Medical Center offers financial assistance for qualified Calhoun County residents.
Charity Program     Indigent Program    
* Type Of Service
(Required)
Lab     X-Ray     Cardio     Surgery     Physical Therapy     Other    
  Appointment Date
Please provide your scheduled appointment date if available.
* Ordering Physician
Doctor who signed the Order (Required)
* Primary Physician
Family Physician (Required)