Pre-Registration: St. Bernardine Medical Center

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

Name of Submitter (last, first) *

Phone Number *

Submitter Relationship to Patient

Type of Procedure

Diagnosis

Inpatient/ Outpatient/ Maternity Procedure *

Inpatient

Outpatient

Maternity

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

* If the accident or injury is work related you must provide the date and time of the accident or injury.

Accident Work Related?

Yes

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

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 *

Employer Name *

Employer Phone *

Occupation

Employer Address

Employer Suite Number

Employer City

Employer State or Province

Employer Zip or Postal Code

Employer Country

Retirement Date *

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

Guarantor Information

Is the Patient the Guarantor? *

Yes

Relationship to Patient *

Last Name *

First Name *

Social Security Number

Birth Date *

Gender *

Male

Female

Street Address *

Apartment or Unit Number

City *

State or Province *

Zip or Postal Code *

Country

Phone Number *

Email Address

Employment Status *

Employer Name *

Employer Phone *

Occupation

Employer Street Address

Employer Suite Number

Employer City

Employer State or Province

Employer Zip or Postal Code

Employer Country

Retirement Date *

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

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

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

Patient Relationship to Subscriber *

Subscriber Last Name *

Subscriber First Name *

Subscriber Birth Date *

Subscriber Gender *

Male

Female

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 *

Subscriber Employment Status *

Is Primary Insurace through Employer?

Yes

Employer Name *

Employer Phone *

Occupation

Employer Street Address

Employer Suite

Employer City

Employer State or Province

Employer Zip or Postal Code

Employer Country

Subscriber Retirement Date *

Secondary Insurance Information

Does the Patient Have Secondary Insurance? *

Yes

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

Is the Patient the Insurance Subscriber? *

Yes

Patient Relationship to Subscriber *

Subscriber Last Name *

Subscriber First Name *

Subscriber Birth Date *

Subscriber Gender *

Male

Female

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 *

Is Secondary Insurace through Employer? *

Yes

Employer Name *

Employer Phone *

Occupation

Employer Street Address

Employer Suite

Employer City

Employer State or Province

Employer Zip or Postal Code

Employer Country

Subscriber Retirement Date *

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