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Lindsborg Community Hospital

Lindsborg Community 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
* Marital Status Single     Married     Divorced     Widowed    
* Date of Birth
* Home Phone
Area Code and 7 Digit Number
* Cell Phone
If you do not have a cell phone "none" can be entered.
* Street Address
Full Street Address or P.O. Box
* City
* State
* Zip Code
  Employer's Name
If you are employed please list your major employer's business name.
  Spouse's Name
  Spouse's Date of Birth
  Cell Phone
  Employer
Health Insurance Information
* Insurance Name
* Identification Number
* Group Number
* Cardholder Name
* Cardholder Date of Birth
* Relationship to Patient
  Secondary Insurance
(If applicable)
  Insurance Name
  Identification Number
  Group Number
  Cardholder Name
  Cardholder Date of Birth
  Relationship to Patient
Guarantor Information
Person responsible for bill
* Name
* Social Security Number
Nine Digit Social Security Number
* Date of Birth
* Home Phone
  Cell Phone
* Street Address
Full Street Address or P.O. Box
* City
* State
* Zip Code
Emergency Contact
  Name
  Home Phone
  Cell Phone
  Work Phone