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Kimball Health Services

Hospital Visit Pre-Registration

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.
* Scheduled Visit Date
* Ordering Physician
The doctor who ordered your service
* 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    
* Patient Full Name
First Name, Middle Initial, Last Name
* Patient Address
Full Street Address or P.O. Box
* City, State & Zip
* County
* Telephone
Area Code and 7 Digit Number
* Date of Birth
Month/Day/Year
* Social Security Number
Nine Digit Social Security Number
* Sex Male     Female    
* Race White     Hispanic     Black     Asian     Indian    
* Religion
* Marital Status Single     Married     Separated     Divorced     Widowed    
* Insurance Information
Name of Insurance Company and mailing address (i.e. Blue Cross, Medicare, Medicaid, Champus, or Self-Pay)
  Insurance Numbers
Patient's ID # and group # if applicable
* Are you employed? Yes     No    
  Employer's Name
If you are employed please list your major employer's business name.
  Employer's Address
Street, City, State, Zip
  Occupation
  Retirement Date
Fill In This Field Only If You Expect To Retire.
* Payment of Services
How will you pay for any non-covered charges?
Check     Cash     Credit Card    
* Minor Status
Is the patient under age 19?
Yes     No    
  Parent or Guardian Information
If patient is a minor please enter Parent or Guardian's full name
  Parent or Guardian
Parent/Guardian's mailing address, Date of Birth, SSN, Phone, Race, Marital Status & Gender.
  Responsible Party Information
Fill Out Below if the Patient is not the person responsible for the bill
  Person Responsible For Bill
Full Name of Individual or Employer (for Worker's Comp)
  Relationship To Patient
  Responsible Party's Date of Birth
  Responsible Party's Address
Street, City, State, Zip
  Responsible Party's Telephone Number
Area Code and 7 Digit Number
  Responsible Party's Sex Male     Female    
  Responsible Party's SSN
Nine Digit Social Security Number
  Responsible Party's Employer
If the responsible party is employed please list his/her major employer's business name
  Employer's Address
Street, City, State, Zip
  Employer Phone Number
Area Code Plus 7 Digit Number
  Responsible Party's Occupation
* Emergency Contact Information
Please Type In Full Name, Relationship, Address, Telephone