Joint Notice of Privacy Practices
                 

Please fill out all pertinent information. Required fields are indicated by an asterisk (*).

Gather any materials you may need to complete the registration , and refresh this page before continuing.

To fill out the Pre-Registration Form,

  • you must be at least eighteen (18) years of age, and
  • must acknowledge that you have read the Patient Privacy Notice.

Yes, I am at least eighteen years of age.

Yes, I acknowledge that I have received a copy of the Patient Privacy Notice.

 

Pre-Registration Form
 * Please Select a Hospital
 * Name of Submitter (last, first):  * Phone Number:   Submitter Relationship to Patient:
  Type of Procedure: * Inpatient/
Outpatient/
Maternity
Procedure:
Inpatient
Outpatient
Maternity
  Diagnosis:
  Procedure to be Performed:  * Procedure Date:   Procedure Time:
  Procedure Auth., if known:   Last Menstrual Period, if pregnant:   Injury or Illness
due to an accident:
Yes
No
* If the accident or injury is work related you must provide the date and time of the accidient or injury.
  Accident Work Related? Yes
No
  Date of Injury or Accident:   Time of Injury or Accident:
* Please provide information for at least one of the following: Admitting Doctor, Newborn Pediatrician, or Primary Care Physician.
  Admitting Doctor Name (last, first):   Admit Doctor Phone Number:      
  Newborn Pediatrician Name (last, first):   Newborn Pediatrician Phone Number:      
  Primary Care Physician Name(last, first):   Primary Care Physician Phone Number:      
 
Patient Information
  Title (if applicable):            
* Last Name  * First Name   Middle Initial
  Maiden Name or
Other Name
* Birth Date   Patient Social Security Number
 * Gender
Male
Female
* Does the patient have an Advance Directive?
(If yes, please bring a copy to hospital)
Yes
No
     
 * Religious Preference
 * Marital Status
 * Race/ Ethnicity
 * Primary Language
 * Address
(street or mailing)
  Apartment or Unit Number * City
 * State or Province * Zip or Postal Code   Country
* Please provide at least one phone number.
  Mobile Phone   Home Phone   Other Phone
 * Preferred Phone
 * Employment Status
Email Address
  Would you like secure access to the Dignity Health Online Patient Center to access your medical records (patient email address required for access)?
Yes
No
 
 
Guarantor Information
 * Is the Patient the Guarantor?
Yes
No
           
 
Emergency/Primary Contact
 * Relationship to Patient  * Last Name  * First Name
 * Street Address   Apartment or Unit Number  * City
 * State or Province  * Zip or Postal Code      
* Please provide at least one phone number.
  Mobile Phone Number   Home Phone Number   Other Phone Number
 * Preferred Phone
 
Prior Hospital Stay
 * Prior Hospital Stay?
Yes
No
           
 
Primary Insurance Information
* Is the patient covered by either Original Medicare , a Medicare Managed Care Plan, a Medicare Choice + Plan, or a Medicare HMO plan ?
Yes
No
     
  Insurance Company Name            
 * Policy or Claim Number   Plan Group Number  * Group Name
  Insurance Address   Insurance Suite Number   Insurance City
  Insurance State or Province   Insurance Zip or Postal Code   Insurance Country
  Insurance Phone Number            
 * Is the Patient the Insurance Subscriber?
Yes
No
         
 
Secondary Insurance Information
 * Does the Patient Have Secondary Insurance?
Yes
No
           
 
Comments
Please enter any additional questions or comments here  
 


If you miss your appointment, we reserve the right to delete your submitted information from our records after 30 days.