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Mercy Hospital Jefferson

Patient Pre-Registration Application

The following questionaire allows you to Pre-Register in advance of your scheduled hospital procedure or test. Completing this form will ensure we have the correct personal and insurance information when you arrive at the hospital.

Fields marked with a * are required fields.
Please call 636 933 1860 if you have any questions. The Pre-Registration department is open 7:30 a.m. - 6:00 p.m., Monday - Friday.
Patient Information
* Date of Procedure/Test
* Primary Care Physician
* Ordering Physician
  Do you have a order/prescription from the ordering physician for the scheduled test? yes     no    
* Type of Procedures
* Patient Full Name
First Name, Middle Initial, Last Name
* Street Address
Full Street Address or P.O. Box
* City
* State
* Zip Code
* Home Telephone
Area Code and 7 Digit Number
  Cell Phone
Area Code and 7 Digit Number
* Gender Male     Female    
* Marital Status Single     Married     Divorced     Widow     Widower     Significant Other     Life Partner     Legally Separated    
* Race African American     Asian     Caucasian     Hispanic     Middle Eastern Indian     Multi-Racial     Native American     Other     Pacific Islander    
* Date of Birth
* Social Security Number
Nine Digit Social Security Number
  Religion Preference
* 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
  Employment Status Full Time     Part Time     Retired     Self Employed     Active Military Duty     Student     Unemployed    
  Occupation
  Retirement Date
Fill In This Field Only If You Expect To Retire.
* When Paying Healthcare Bills...How Do You Plan To Pay? Commercial Insurance     Cash     Medicaid     Medicare     Credit Card    
Responsible Party Information
  Responsible Party Information
Fill Out Below If The Patient Is Not The Resonsible Party
If Patient Above Is Responsible Party Then Check This Box
  Person Responsible For Bill
  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
  Employment Status Full Time     Part Time     Retired     Self Employed     Active Military     Student    
  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
Primary Insurance
* Insurance Name
  If Commerical Insurance, Please List
  Insurance Claims Address
Please provide the insurance address where claims are to be submitted.
* Policy ID#
* Group #
* Subscriber Name
* Date Of Birth
* Social Security Number
* Relationship to Patient
  If Other, please list
Secondary Insurance
  Insurance Name
  If Commerical Insurance, Please List
  Insurance Claims Address
Please provide the insurance address where claims are to be submitted.
  Policy ID#
  Group #
  Subscriber Name
  Date Of Birth
  Social Security Number
  Relationship to Patient
  If Other, Please List