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Helen Keller Hospital

Red Bay Hospital Patient Pre-registration Application

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.
Please Print clearly and Complete the following information. This form should take 4 or 5 minutes to complete.
* Patient Full Name
First Name, Middle Initial, Last Name
* Social Security Number
Nine Digit Social Security Number
* Are you a Keller Senior Care Member? yes     no    
* Are you a Keller Gold Card Member? yes     no    
* Date of Birth
* Primary Physician
* Today's Date
* Expected Date of Admission
* Type of Admission
 
If other, please list..
* Street Address
Full Street Address or P.O. Box
* City
* County
* State
* Zip Code
* Telephone
Area Code and 7 Digit Number
* Marital Status
* Sex Male     Female    
* Race Black     White     Asian     Indian    
  Religion
* Are You Employed? Yes     No    
  Employer's Name
If you are employed please list your major employer's business name.
  Employer's Street Address
  City
  State
  Zip Code
Five Digit Zip Code
  Employer Phone Number
Area Code Plus 7 Digit Number
  Occupation
  Retirement Date
Fill In This Field Only If You Expect To Retire.
* When Paying Healthcare Bills...How Do You Plan To Pay? Insurance     Cash     Medicaid     Medicare    
Responsible Party/Guarantor Information
* Name
Is Patient Responsible Party?
yes     no    
  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
Insurance Information
* Name of Primary Insurance
 
If other insurance please list
* Subscriber Name
Name on insurance card or employee name
* Subscriber Social Security Number
* Subscriber Date of Birth
* Subscriber Policy Number
* Subscriber Group Number
Secondary Insurance
  Name of Secondary Insurance
 
If other insurance please list
  Subscriber Name
Name on insurance card or employee name
  Subscriber Social Security Number
  Subscriber Date of Birth
  Subscriber Policy Number
  Subscriber Group Number