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You may send us information prior to your hospital visit. By registering before coming to the hospital you can help ensure accurate information is gathered for your records and is prepared in a timely manner. |
Please complete the following information. This form should take several minutes to complete. Please give us at least 24 hours to process your submission. Please note you must still stop at the front desk to sign other forms prior to your visit. |
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Scheduled Visit Date |
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Ordering Physician The doctor who ordered your service |
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Scheduled Services Select from the following list your scheduled service |
Lab X-ray Ultrasound Mammogram Echocardiogram MRI Cat Scan Bone Density Nuclear Medicine Colonoscopy EGD procedure Sleep Study Outpatient Surgery Other |
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Patient Full Name First Name, Middle Initial, Last Name |
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Patient Address Full Street Address or P.O. Box |
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City, State & Zip |
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County |
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Telephone Area Code and 7 Digit Number |
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Date of Birth Month/Day/Year |
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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 |
White Hispanic Black Asian Indian |
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Religion |
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Marital Status |
Single Married Separated Divorced Widowed |
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Insurance Information Name of Insurance Company and mailing address (i.e. Blue Cross, Medicare, Medicaid, Champus, or Self-Pay) |
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Insurance Numbers Patient's ID # and group # if applicable |
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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's Address Street, City, State, Zip |
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Occupation |
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Retirement Date Fill In This Field Only If You Expect To Retire. |
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Payment of Services How will you pay for any non-covered charges? |
Check Cash Credit Card |
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Minor Status Is the patient under age 19? |
Yes No |
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Parent or Guardian Information If patient is a minor please enter Parent or Guardian's full name |
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Parent or Guardian Parent/Guardian's mailing address, Date of Birth, SSN, Phone, Race, Marital Status & Gender. |
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Responsible Party Information Fill Out Below if the Patient is not the person responsible for the bill |
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Person Responsible For Bill Full Name of Individual or Employer (for Worker's Comp) |
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Relationship To Patient |
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Responsible Party's Date of Birth |
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Responsible Party's Address Street, City, State, Zip |
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Responsible Party's Telephone Number Area Code and 7 Digit Number |
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Responsible Party's Sex |
Male Female |
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Last 4 Digits of Responsible Party's SSN Last 4 Digits of Responsible Party's SSN |
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Responsible Party's Employer If the responsible party is employed please list his/her major employer's business name |
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Employer's Address Street, City, State, Zip |
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Employer Phone Number Area Code Plus 7 Digit Number |
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Responsible Party's Occupation |
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Emergency Contact Information Please Type In Full Name, Relationship, Address, Telephone |
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