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This form is to register for our Patient Pre-registration Program. By registering with us you can receive peace of mind that we have your medical information.
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Please Print clearly and Complete the following information. This form should take 4 or 5 minutes to complete. |
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Today's Date |
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When Paying Healthcare Bills...How Do You Plan To Pay? |
Insurance Cash Medicaid Medicare |
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Type of Preadmit Please enter the type of Preadmit you are doing. |
Ambulatory Care Inpatient Outpatient Lab Outpatient Radiology Outpatient Respiratory Outpatient Physical Therapy Outpatient L&D Other
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PreAdmitDate Enter the date you are to have the test/procedure/admit |
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Orders Do you have the orders from your Doctor? If so you need to bring them with you on the day of your appointment. |
Yes No |
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Patient Full Name First Name, Middle Initial, Last Name |
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Street Address Full Street Address and P.O. Box |
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City |
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State |
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Zip Code |
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County |
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Telephone Area Code and 7 Digit Number |
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Email address |
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Date of Birth |
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Last 4 Digits of Social Security Number Last 4 Digits of Social Security Number |
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Sex |
Male Female |
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Race |
Black White Asian Indian Other |
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Marital Status |
Single Married Divorced Widowed |
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Religion Enter Religious Preference Here. |
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Ethnicity |
Declined Hispanic Not Hispanic Unavailable |
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Language |
English Spanish Asian German Italian Other |
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Reisdent |
US Citizen Non Resident Canadian
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Family Physician |
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Are You Employed? |
Yes No |
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Employer's Name If you are employed please list your major employer's business name. |
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Employer Address Enter entire Address of Employer here. |
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Employer Phone Number Area Code Plus 7 Digit Number |
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Occupation |
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Type of Position |
Full Time Part Time |
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Guarantor Information |
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Responsible Party Information Fill Out Below If The Patient Is Not The Responsible Party |
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Person Responsible For Bill This will be the guarantor. |
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Relationship To Patient |
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Guarantor Address Please put thre guarantor address |
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Guarantor City |
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Guarantor State |
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Guarantor Zip |
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Guarantor Phone Num Please include area code |
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Guarantor Email Address Please enter the Guarantor's Email address |
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Date of Birth Guarantor Date of Birth |
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Guarantor Employer |
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Last 4 Digits of Social Security Number Last 4 Digits of Social Security Number |
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Guarantor Sex |
Male Female |
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Guarantor Marital Status |
Single Married Divorced Widowed
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Guarantor Religion Enter religious preference |
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Guarantor Race |
Black White Asian Indian Other |
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Guarantor Ethnicity |
Declined Hispanic NonHispanic Unavailable |
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Guarantor Language |
English Spanish German Itialian Other |
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Guarantor Resident |
US Citizen NonCitizen Canadian |
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Guarantor Physician |
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Guarantor Employer's Street Address |
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City |
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State |
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Zip Code Five Digit Zip Code |
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Work Phone Number |
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Person To Notify In Case Of An Emergency Please Type In Full Name, Relationship, Address, Area Code & Telephone Number |
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Additional Emergency Contact Please Type In Full Name, Relationship, Address, Area Code & Telephone Number |
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Insurance or Medicare/Medicaid Numbers Please Include Your Primary and Secondary Insurance Numbers or Medicare and Medicaid Numbers. We Need Your Basic Health Insurance Information. Make Sure You Include Your Group Number or Medicare Number. Please Also List Your Effective Date of Coverage. |
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Additional Insurance info Please Include Your Primary and Secondary Insurance Numbers or Medicare and Medicaid Numbers. We Need Your Basic Health Insurance Information. Make Sure You Include Your Group Number or Medicare Number. Please Also List Your Effective Date of Coverage. |
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