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El Campo Memorial Hospital

MCMC Patient Pre-Registration Form

Thank you for choosing Mid Coast Medical Clinic 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.
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.
PATIENT INFORMATION
* Patient's Name
First Name, Middle Initial, Last Name (Required)
* Patientís Street Address
(Required)
* City
(Required)
* State
(Required)
* Zip Code
5 Digit Zip Code (Required)
* Home Phone Number
Area Code and 7 Digit Number (Required)
* Alternate/Cell Phone Number
Area Code and 7 Digit Number
  E-mail Address
* Date of Birth
(Required)
* Race
(Required)
African American     Caucasian     Asian     Hispanic     Other    
* Age
* Sex
(Required)
Male     Female    
* Last 4 Digits of Social Security Number
Last 4 Digits of Social Security Number
* Driverís License Number
* Marital Status
(Required)
Single     Married     Divorced     Other    
  Patientís Employer
If you are employed please list your employer's business name.
  Occupation
  Work Telephone Number
Area Code Plus 7 Digit Number
  Employer's Street Address
  City
  State
  Zip Code
5 Digit Zip Code
  Spouseís Name
  Date of Birth
  Last 4 Digits of Social Security Number
Last 4 Digits of Social Security Number
  Driverís License Number
  Work Telephone Number
Area Code and 7 Digit Number
  Spouseís Employer
  Employerís Address
  City
  State
  Zip Code
5 Digit Zip Code
INSURANCE INFORMATION - Please present your insurance card to the front desk
  Primary Insurance Company
  Policyholder
  Certificate Number
  Group Number
  Secondary Insurance Company
  Policyholder
  Certificate Number
  Group Number
EMERGENCY CONTACT INFORMATION
  Nearest Local Relative Not Living With You
  Street Address
  City
  State
  Zip Code
5 Digit Zip Code
  Telephone Number
Area Code and 7 Digit Number
IF A PATIENT IS A MINOR OR A STUDENT
  Fatherís Name
  Street Address
  City
  State
  Zip Code
5 Digit Zip Code
  Home Telephone Number
Area Code and 7 Digit Number
  Fatherís Employer
  Work Telephone
Area Code and 7 Digit Number
  Last 4 Digits of Social Security Number
Last 4 Digits of Social Security Number
  Driverís License Number
  Date of Birth
  Motherís Name
  Street Address
  City
  State
  Zip Code
5 Digit Zip Code
  Home Telephone Number
Area Code and 7 Digit Number
  Motherís Employer
  Work Telephone
Area Code and 7 Digit Number
  Last 4 Digits of Social Security Number
Last 4 Digits of Social Security Number
  Driverís License Number
  Date of Birth
I hereby authorize Mid Coast Medical Clinic Physicians, Physician Assistants and/or staff to discuss my protected health information with:
  Name
  Relationship
  Telephone Number
Area Code and 7 Digit Number
AUTHORIZATION FOR TREATMENT AND/OR SURGERY
The patient and others whose signatures are attached below do hereby consent to any and all medical surgical treatments, including anesthetics and operations, which may be deemed advisable by his or her physicians or physician assistant/nurse practitioner serving on the staff of Mid Coast Medical Clinic, the intention hereof being to grant authority to administer and to perform all and singular any examinations, treatments, anesthetics, operations and diagnostic procedures which may now or during the course of the patientís care be deemed advisable or necessary.
ASSIGNMENT OF BENEFITS
I/We hereby transfer, assign and convey all my/our rights, title and interest in and all benefits due me/us, if any, by reason of services described in the statements rendered, and as provided for in any contract or policy of insurance under which I/we may be an insured or beneficiary and I direct said insurance company(s) and Medicare to pay directly to Mid Coast Medical Clinic, all of such benefits. I/we also assign my/our causes of action against any and all third parties who may be responsible or liable for the injuries requiring admission to or treatment by Mid Coast Medical Clinic, up to but not to exceed the amount of charges described in the statements rendered. I agree to pay Mid Coast Medical Clinic any remaining balance after insurance payment or denial of coverage under this assignment of benefits. I also authorize the release of any information required in the processing of my healthcare claims.
AUTHORIZATION/PRECERTIFICATION
If my group or private insurance policy requires prior certification, authorization, second opinions, or any other type of utilization review function, I understand that I am responsible for compliance with these and all other terms of my policy.
PATIENT FINANCIAL RESPONSIBILITY
Mid Coast Medical Clinicís election to pursue one or more forms of collection shall not constitute a waiver of its right to pursue other collection measures it deems advisable or necessary. All such remedies shall be cumulative in nature. Venue for collection shall be Wharton County, Texas This agreement shall not require payment by any person in contravention of any state or federal statute, rule or regulation.
ADVANCE DIRECTIVE ACKNOWLEDGMENT
* Do you have a living will?
* Would you like information on a living will?
CONSENT TO TESTING AFTER BLOOD OR BODY FLUID EXCHANGE
I understand, agree, and authorize that in the event a health care worker is exposed to my blood or body fluids, my blood will be tested at no cost to me. The undersigned certifies that he/she has read this entire document and is the patient, or is duly authorized by the patient or by the law to execute the above agreement and accepts and understands its terms.
MID-LEVEL PRACTITIONER ACKNOWLEDGEMENT
I acknowledge that it is the policy of Mid Coast Medical Clinic to delegate healthcare tasks or general medical services to a qualified physician assistant or nurse practitioner. This allows for more effective utilization of the skills of the physicians. Delegation of such duties is consistent with due regard for the health and safety of our patients and in keeping with sound medical practice. I fully understand that the physician assistant or nurse practitioner is NOT A PHYSICIAN, and that I have the right to insist at any time on seeing any licensed physician providing services at this clinic. I further acknowledge that the general medical services provided my by a physician assistant or nurse practitioner are the responsibility of the physicians providing services at this clinic both professionally and legally, for the acts of such allied health personnel rendered during the care and treatment of his/her patients. I have read the above in its entirety and fully understand the Mid Coast Medical Clinicís policy regarding physician assistants and/or nurse practitioners and do hereby consent to receiving general medical services from a physician assistant or nurse practitioner as may be assigned.
  Signature of Patient or Legally Authorized Representative
  Today's Date