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Montgomery County Memorial 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
* Primary Physician
* Appointment Date
* Street Address
Full Street Address or P.O. Box
* City
* County
* State
* Zip Code
* Telephone (Primary)
Area Code and 7 Digit Number
  Telephone (Secondary)
Area Code and 7 Digit Number
  Email Address
* Date of Birth
* Marital Status
Choose One:
Single     Married     Divorced     Widowed     Life Partner     Separated    
* Sex
Choose One:
Male     Female    
* Race
Choose One:
Black     White     Asian     Indian     Other    
* Language Spoken
* Social Security Number
Nine Digit Social Security Number
* Do you have a religious preference or church affiliation?
  If yes, please state your religious preference or church affiliation.
  Living Will & Medical Power of Attorney at MCMH
Please select one of the following:
* Are You Employed? Choose One     Yes     No    
  Are you a MCMH Employee?
  Do you have a spouse or parent who is employed at MCMH?
  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
  Type of Position
Choose One:
Full Time     Part Time    
  Occupation
  Are you retired or disabled?
  If Yes, Retirement Date?
* When Paying Healthcare Bills...How Do You Plan To Pay?
Choose One:
Insurance     Cash     Medicaid     Medicare    
  Responsible Party Information
Fill Out Below If The Patient Is Not The Resonsible Party
  Person Responsible For Bill
If Patient is a Minor, Who Does Child Live With?
  Date of Birth
  Street Address or P.O. Box
  City
  State
  Zip Code
Five Digit Zip Code
  Telephone (Primary)
Area Code and 7 Digit Number
  Telephone (Secondary)
Area Code and 7 Digit Number
  Sex
Choose One:
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
Choose One:
Full Time     Part Time    
  Responsible Party's Occupation
* Person To Notify In Case Of An Emergency #1
Please Type In Full Name, Relationship, Address, Area Code & Telephone Number
  Person To Notify In Case Of An Emergency #2
Please Type In Full Name, Relationship, Address, Area Code & Telephone Number
Insurance or Medicare/Medicaid Numbers
Please include all information
  If Medicare: VA
Black Lung
End Stage Renal Disease
* Primary Insurance
Medicare or Medicaid if applicable
  Insurance Policy Number
  Group Number, If Applicable
* Secondary Insurance
Medicare or Medicaid if applicable
  Insurance Policy Number
  Group Number, If Applicable
  Medical Claims Address
(Found on Card)
  Who carries the insurance?
  Is this visit due to an accident?
  If yes, when did the accident occur?
  Accident Description: