|
|
|
|
|
|
|
|
|
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
|
|
* |
Retirement Date |
|
|
|
|
|
|
|
* |
Employer Name |
|
* |
Employer Phone |
|
|
Occupation |
|
|
Employer Address |
|
|
Employer Suite Number |
|
|
Employer City |
|
|
Employer State or Province |
|
|
Employer Zip or Postal Code |
|
|
Employer Country |
|
|
Guarantor Information
|
* |
Is the Patient the Guarantor?
|
Yes
No
|
|
|
|
|
|
|
* |
Relationship to Patient |
|
* |
Last Name |
|
* |
First Name |
|
* |
Birth Date |
|
* |
Gender |
Male
Female
|
|
Social Security Number |
|
* |
Street Address |
|
|
Apartment or Unit Number |
|
* |
City |
|
* |
State or Province |
| * |
Zip or Postal Code |
|
|
Country |
|
* |
Phone Number |
|
|
|
|
|
|
|
* |
Employment Status |
|
|
Email Address |
|
* |
Guarantor Retirement Date |
|
|
|
|
|
|
|
* |
Employer Name |
|
* |
Employer Phone |
|
|
Occupation |
|
|
Employer Street Address |
|
|
Employer Suite Number |
|
|
Employer City |
|
|
Employer State or Province |
|
|
Employer Zip or Postal Code |
|
|
Employer Country |
|
|
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
|
|
|
|
|
|
|
* |
Name of Prior Stay Facility |
|
* |
Approximate Admit Date |
|
* |
Approximate Discharge Date |
|
|
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
|
|
|
|
|
|
|
* |
Patient
Relationship to Subscriber
|
|
* |
Subscriber Birth Date
|
|
* |
Subscriber Gender |
Male
Female
|
|
Subscriber Social Security
Number
|
|
* |
Subscriber Last Name |
|
* |
Subscriber First Name |
|
* |
Subscriber Street Address: |
|
|
Subscriber Apartment or Unit Number: |
|
* |
Subscriber City |
|
* |
Subscriber State or Province: |
|
|
Zip or Postal Code |
|
* |
Subscriber Country: |
|
* |
Please provide at least one phone number. |
|
Subscriber Mobile Phone: |
|
|
Subscriber Home Phone |
|
|
Subscriber Other Phone |
|
* |
Preferred Phone |
|
* |
Subscriber Employment Status: |
|
* |
Subscriber Retirement Date |
|
|
|
|
|
|
|
|
Is Primary Insurace through Employer? |
Yes
No
|
|
|
|
|
|
|
* |
Employer Name |
|
* |
Employer Phone Number |
|
|
Occupation |
|
|
Employer Street Address: |
|
|
Employer Suite: |
|
|
Employer City: |
|
|
Employer State or Province: |
|
|
Employer Zip or Postal Code: |
|
|
Employer Country: |
|
|
Secondary Insurance Information
|
* |
Does the Patient Have Secondary Insurance? |
Yes
No
|
|
|
|
|
|
|
|
Insurance Company Name: |
|
|
|
|
|
|
|
* |
Policy or Claim
Number:
|
|
|
Plan Group Number: |
|
* |
Group Name: |
|
|
Insurance Street 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
|
|
|
|
|
|
|
* |
Patient
Relationship to Subscriber:
|
|
* |
Subscriber Birth Date |
|
* |
Subscriber Gender |
Male
Female
|
* |
Subscriber
Last Name:
|
|
* |
Subscriber First Name |
|
|
Subscriber Social Security Number
|
|
* |
Subscriber Street Address |
|
|
Subscriber Apartment or Unit Number |
|
* |
Subscriber City |
|
* |
Subscriber State or Province |
|
* |
Zip or Postal Code |
|
|
Subscriber Country |
|
* |
Please provide at least one phone number. |
|
Subscriber Mobile Phone |
|
|
Subscriber Home Phone |
|
|
Subscriber Other Phone |
|
* |
Preferred Phone |
|
* |
Employment Status |
|
|
|
|
|
|
|
* |
Subscriber Retirement Date |
|
|
|
|
|
|
|
* |
Is Secondary Insurace through Employer? |
Yes
No
|
|
|
|
|
|
|
* |
Employer Name |
|
* |
Employer Phone Number |
|
|
Occupation |
|
|
Employer Address |
|
|
Employer Suite |
|
|
Employer City |
|
|
Employer State or Province |
|
|
Employer Zip or Postal Code |
|
|
Employer Country |
|
|
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.
|