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Millinocket Regional 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
* Referring Physician
Please list the physician that referred you to CRMC for your test. If none, please state not applicable.
* Today's Date
* Procedure/Test Date
If your procedure/test is scheduled, please indicate date. If not scheduled (lab), plesae state not scheduled.
* Street Address
Full Street Address or P.O. Box
* City
* County
* State
* Zip Code
* HomeTelephone Number
Area Code and 7 Digit Number
  Cellular Phone
Please provide your cellular phone number if applicable.
* Date of Birth
* Marital Status Single     Married     Divorced     Widowed    
* Sex Male     Female    
* Race Black     White     Asian     Indian     Hispanic     Other    
* Social Security Number
Nine Digit Social Security Number
* Religion
* Are You Employed? Yes     No    
* Employer's Name
If you are employed please list your major employer's business name. If not employed, please list retired, disabled, not employed, etc.
  Employer's Street Address
  City
  State
  Zip Code
Five Digit Zip Code
  Employer Phone Number
Area Code Plus 7 Digit Number
  Type of Position Full Time     Part Time    
  Occupation
  Retirement Date
Fill In This Field Only If You Expect To Retire.
* When Paying Healthcare Bills...How Do You Plan To Pay? Insurance     Cash     Medicaid     Medicare    
* 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
  Type of Position Full Time     Part Time    
  Responsible Party's Occupation
* Person To Notify In Case Of An Emergency
Please Type In Full Name, Relationship, Address, Area Code & Telephone Number
  Alternate Contact
Please list someone outside your home in case we need to reach you.
  Insurance or Medicare/Medicaid Numbers
Please Include Your Primary and Secondary Insurance Numbers or Medicare and Medicaid Numbers. We Need Your Basic Health Insurance Information. Make Sure You Include Your Group Number or Medicare Number. Please Also List Your Effective Date of Coverage.