Accident: Some examples of types of accidents for which the patient is being treated are as follows: Motor Vehicle Accident, Accident occurred at patient's own home, Accident - Crime Victim, Accident in someone else's house, Accident occurred in a public area, Drowning Accident, Job-related Accident, Self-inflicted Accident, Accident 3rd parties involved.


Accident Work Related: Answer whether the patient's accident was job related. The allowable values for this field are as follows: Yes, the patient's accident was job related. No, the patient's accident was not job related.


Address: Complete the mailing address. Approved abbreviations are:
N - North
E- East
S- South
W- West
LN - Lane
WY - Way
PKWY - Parkway
BLVD - Boulevard
APT- Apartment
PL - Place
SP- Space
RR - Rural Route
ST- Street
RT - Route
AVE- Avenue
PO BOX - Post Office Box
RD- Road
# - Number



Admitting Physician: The name of the doctor responsible for admitting the patient to a hospital or other inpatient health facility.



Advance Directive: Written ahead of time, a health care advance directive is a written document that says how the patient wants medical decisions to be made if they lose the ability to make decisions for themselves. A health care advance directive may include a Living Will and a Durable Power of Attorney for health care.


Beneficiaries: The name for a person who has health insurance through Medicare or an insurance plan.


Birth Date: Depending on what section you are answering this question, enterthe patient's, guarantor's or subscriber's birthdate in MM/DD/YYYY American format, where MM is the birth month, DD is the birth day, and YYYY is the birth year. Insurance priority is sometimes determined by birthdate order in the calendar year.


City: Enter the name of the city that is part of the mailing address.



Coordination Period (30 month coordination period): A period of time when the employer group health plan will pay first on a patient's health care bills and Medicare will pay second. If the employer group health plan doesn't pay 100% of the patient's health care bills during the coordination period, Medicare may pay the remaining costs.


Country: Enter the name of the country that is part of the mailing address.You do not need to answer this if it is for addresses in the U.S.A. United States of America.


Date or Time of Injury or Accident: Enter the date of the patient's accident. If a date is entered, the time of the accident must also be entered. Enter the accident date in MM/DD/YYYY format, where MM is the month, DD is the day, and YYYY is the year. Enter the accident time in HH:MM format, where HH is the hours and MM is the minutes.


Description of Injury/Illness: Describe the accident in a written account answering what happened? Was it a fall, was the patient struck by person or object or vehicle? What part(s) of the body was/were injured? Where was the location of the patient's accident? Home, work*,school*, public street, restaurant*, job site* and retailstore* are all examples of location. *Actual name and address of facility or site should be included.


Diagnosis: The name that describes the health problem that patient has or is seeking treatment for. The reason the patient is being treated.


End-Stage Renal Disease (ESRD) Permanent kidney failure that is severe enough to require lifetime kidney dialysis or a kidney transplant.


Employer Goup Health Plan (GHP): A GHP is a health plan that provides health coverage to employees, former employees, and their families, and is supported by an employer or employee organization.


Employment status: Depending on what section you are answering this question, identify the employment status of either the patient, the subscriber or the guarantor. Employed Full Time, Employed Part Time, Unemployed, Self-Employed, Retired, Active Military Duty.


Entitlement: The reason the patient became eligible for Medicare benefits. The reason can be by Age, Disability or End-Stage Renal Disease.


Ethnicity: Ethnic character, background, or affiliation. An ethnic group. Of or relating to a sizable group of people sharing a common and distinctive racial, national, religious, linguistic, or cultural heritage.


First Name: Depending on what section you are answering this question, enter the patient's, guarantor's or subscriber's first name. This name should be the full legal first name rather than a personal preference, nickname, or initial.


Gender: Enter the person's gender or sex. The allowable values are as follows: M - Male F - Female


Group Name:Enter the name of the insurance group or plan defined for the patient's account. Please refer to the insurance card for this information. Answers for this field can include letters, numbers, and spaces.


Group Number: Enter the identification number or code used for group coverage by the carrier or administration to identify the patient's insurance group. Please refer to the insurance card for this information. Answer can include letters, numbers, and spaces.



Guarantor: The person who ultimately accepts financial responsibility to pay the patient's bill. In most cases it is the adult patient receiving the service.If the patient is a child, the responsible party may be the child's parent or legal guardian. The guarantor should not be confused with the subscriber of the insurance. This may or may not be the same person.


Injury or Illness Due to an Accident: Some examples of types of accidents for which the patient is being treated are as follows: Motor Vehicle Accident, Accident occurred at patient's own home, Accident - Crime Victim, Accident in someone else's house, Accident occurred in a public area, Drowning Accident, Job-related Accident, Self-inflicted Accident, Accident 3rd parties involved.


Inpatient/Outpatient/Maternity Procedure: Answer Inpatient if your doctor has indicated you will be admitted to remain in a hospital bed for one or more days. Answer Outpatient if the service requires a stay of less than 24 hours or is done in an outpatient department. Answer Maternity if this procedure is related to the delivery of a newborn baby.


Insurance Information: Policy/Claim Number, Plan Group Number, and Group Name may be found on the insurance subscriber's insurance card.


Insurance Name: Enter the name of the insurance company that issued the policy. Please refer to the insurance card for this information. Generally found on the back of the insurance card where claims are mailed to.


Last Menstrual Period: The date your last period started. This is used to calculate your due date and the date from which your 40 weeks of pregnancy officially starts.


Last Name: Depending on what section you are answering this question, enter the patient's, guarantor's or subscriber's last name. This name should be the full legal last name rather than a personal preference, nickname, or initial. Examples: Mc Donald = mcdonald (no space) O'Brien = obrien (no apostrophe, no sapce) Smith-Jones = smith jones (use a space and not a hyphen) St. James = st james (do not use period)


Maiden Name: Enter the maiden name of a married female patient. This name should be the full legal last name rather than a personal preference, nickname, or initial.


Marital Status: Enter the marital status of the patient, for example: Single, Married, Separated, Divorced.


Materials You May Need to Complete the Registration: All applicable Health Insurance cards or documents which include the Insurance company name, insurance policy number and insurance billing address and insurance phone numbers. Birthdates, names, resident mailing addresses and phone numbers of the patient, subscriber and guarantor. Employer names, employer addresses and employer phone numbers for the patient, subscriber and guarantor. Name and address and phone number of person who is the Emergency/Primary contact for the patient.


Medicare: A federal program of healthcare insurance for the aged, totally disabled and those with end-stage renal disease. Benefits provided under title XVIII of the United States Social Security Act of 1965 as amended from time to time. Medicare part A pays for hospital services. Medicare part B is the voluntary part of medicare that pays a percentage of reasonable and customary costs for physician and ancillary services.


Medicare HMO: A type of Medicare managed care plan where a group of doctors, hospitals, and other health care providers agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. In an HMO (Health Maintenance Organization),the beneficiary usually must get all their care from the providers that are part of the plan. There may be restrictions where the beneficiary may only go to certain hospitals or physicians.An alternative to the Original Medicare Plan which replaces the Original Medicare Plan and often named as Senior plans following the name of the insurance.


Medicare Managed Care Plan: These are health care choices (like HMOs) in some areas of the country. In most plans,the beneficiary can only go to doctors, specialists, or hospitals on the plan's list. Plans must cover all Medicare Part A and Part B health care. Some plans cover extras, like prescription drugs. Costs may be lower than in the Original Medicare Plan. An alternative to the Original Medicare Plan which replaces the Original Medicare Plan and often named as Senior plans following the name of the insurance.

Medicare Private Fee-for-Service plans. A private insurance plan that accepts people with Medicare.They may go to any Medicare-approved doctor or hospital that accepts the plan's payment. The insurance plan, rather than the Medicare program, decides how much it will pay and what the beneficiary will pay for the services they get. The beneficiary may pay more for Medicare-covered benefits. They may have extra benefits the Original Medicare Plan does not cover. An alternative to the Original Medicare Plan which replaces the Original Medicare Plan and often named as Senior plans following the name of the insurance.


Medicare Plan (Original): (sometimes called fee-for-service) - Everyone with Medicare can join the Original Medicare Plan. This plan is available nationwide. A pay-per-visit health plan that lets the covered patient go to any doctor, hospital, or other health care provider who accepts Medicare.You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance). The original Medicare plan has two parts: Part A (Hospital Insurance) and Part B (Medical insurance).

Medicare Part A: Hospital Insurance which pays for Inpatient care in hospitals, critical access hospitals, skilled nursing facilities, hospice care and some home health care.

Medicare Part B: Medical insurance which helps pay for Outpatient hospital care, doctor's services and some other medical services that Part A does not cover such as physical and occupational therapies, and some home health care. Medicare or surgical care that Medicare Part B helps pay for and does not include an overnight hospital stay, including:blood transfusions; certain drugs; hospital billed laboratory tests; mental health care; medical supplies such as splints and casts; emergency room or outpatient clinic, including same day surgery; and emergency room or outpatient clinic, including same day surgery; and x-rays and other radiation services.


MSP/Medicare Secondary Payer: Medicare Questionnaire: Questions mandated by the hospital's provider agreement with Medicare to ask all Medicare beneficiaries upon every inpatient and outpatient admission. In order to conform to the law and regulations, the provider (hospital) must verify MSP information prior to submitting a bill to Medicare. It is a guide to identify other payers which may be primary to Medicare. Beginning with part 1, answer each question in sequence. Comply with any instructions which follow an answer. If the instructions direct you to go to another part, answer, in sequence, each question under the new part.


Medicare + Choice (pronounced "Medicare plus Choice") plans. A Medicare program that givesthe patientmore choices among health plans. Everyone who has Medicare Parts A and B is eligible, except those who have End-Stage Renal Disease. There are two types of Medicare + Choice plans. Medicare + Choice plansare offered by private insurance companies (approved by Medicare) which provide care under contract to Medicare. Medicare + Choice plans include:1. Medicare Managed Care Plan and 2. Medicare Private Fee-for-Service plans. An alternative to the Original Medicare Plan which replaces the Original Medicare Plan and often named as Senior plans following the name of the insurance.


MSP Provision: This question pertains if the patient has dual coverage (i.e. entitlement based on Age and ESRD or Disability and ESRD) and the initial entitlement was Age or Disability.


Name of Submitter: Enter the name of the person submitting the form, if you are completing this on behalf of someone else.


Newborn Pediatrician: A doctor specializing in the branch of medicine that deals with the care of infants and children and the treatment of their diseases.


Occupation: Depending on what section you are answering this question, enter the patient's, guarantor's or subscriber's occupation or job title. Enter a specific occupation, such as teacher, doctor, carpenter, etc. Homemaker and student are valid occupations. Enter the name and address of the student's school in the Employer field. Self-employed people should include their type of work.


Patient Relationship to the Subscsriber: This field contains a code indicating the patient's relationship to the subscriber. The subscriber is the person subscribing to or carrying the insurance plan for the patient case. How is the patient related to the subscriber? For example, if the subscriber is the mother of the patient, then the Patient Relationship to Subscriber is Child. Answer: how is the patient related to the subscriber? The patient is a child of the subscriber. Allowable values are as follows: Child, Parent, Step-Child, Patient is Insured (carries insurance on themselves), Foster Child, Grandparent, Grandchild, Spouse, Ward of the Court, Other.


Phone Number: Enter the telephone number requested in the question inlcuding the three-digit area code prefix that is associated with the telephone number and the seven-digit telephone number. For international telephone numbers, please include the country code and city code (routing) codes in front of the actual telephone number.


Policy Number: Enter the policy number for the patient's insurance plan. Please refer to the insurance card for this information. For Medicare plans, enter the patient's Medicare number. For all other plans, enter the insurance plan policy number. The answer can include letters, numbers, and spaces.


Primary Care Physician / Personal Care Physician: In an HMO plan, the PCP is responsible for providing covered healthcare services and for coordinating referrals to other network providers when specialized care is required.The PCP may be trained in family practice, internal medicine, pediatrics, or general practice.


Primary Insurance or Primary Payer: An insurance policy, plan, or program that pays first on a claim or bill from the hospital for medical care. This could be Medicare or other commercial health insurance.


Primary Language: What is the primary language of the patient? Enter another language if you prefer to have some documents provided to you in this language.


Prior Admission Date: Enter the admission date of the patient's last hospital stay. The day the patient began their last hospital inpatient stay.


Prior Discharge Date: Enter the discharge date of the patient's last hospital stay. The day the patient went home from their last hospital inpatient stay.


Prior Hospital:Enter the name of the hospital where the patient has been admitted just before this visit.


Prior Stay: Has the patient been admitted to a hospital previously? If yes, provide the name of the most recent facility and dates of admission and discharge from that facility.


Procedure: Something done to fix a health problem or to learn more about it. For example, surgery, tests, and putting in an IV (intravenous line) are procedures.

Procedure Authorization: Agreement by insurance company to pay for medical services. Physicians and hospitals ask the insurance company for this approval before providing medical services. Failure to get the approval often results in a penalty to the patient since the services may not be covered by insurance.

Procedure Date: Enter the appointment date that you have been given for your procedure to be performed. The date should be entered in MM/DD/YYYY format.

Procedure Time: Enter the appointment time that you have been given for your procedure to be performed.

Provider: A doctor, hospital, health care professional, or health care facility.


Referral: An OK from the patient's primary care doctor for them to see a specialist or get certain services. In many managed care plans, the patient needs to get a referral before they get care from anyone except their primary care doctor. If they do not get a referral first, the plan may not pay for their care.


Refresh: Refreshing the pre-registration web page will restart the timer on the alloted amount of time to fill out the form. The given time to fill out the pre-registration form is 24 minutes. Please note that refreshing a page will clear any data that has been entered already on the page! A web page can be refreshed several ways; by clicking the refresh icon (usually located at the top of your browser), the F5 key on your keyboard, or in Internet Exploer or Netscape browsers by clicking the View menu, then on refresh.


Relationship to Patient: Enter the emergency or primary contact's relationship to the patient. The allowable values are as follows: Mother, Sibling, Father, Friend, Spouse, Grandparent, Emancipated Minor, Child, Legal Guardian, Grandchild, Other


Religion: Enter the patient's religous preference.


Required Answers/Fields: Required fields are indicated by an asterisk to the left of the field description. An answer must be entered for each of these fields. The information is necessary for on-line pre-registration. If you do not have the required information, please gather the information before proceeding. The computer will not submit the registration without this data.


Secondary Insurance or Payer: An insurance policy, plan, or program that pays second on a claim or bill from the hospital for medical care. This could be Medicare, Medicaid, or other health insurance depending on the situation.


Social Security Number: The allowable values are the 9 numbers that make up a valid Social Security number or a valid Railroad Retirement number.


State: Enter the full name for the state (for the United States) or province (for Canada).


Submitter Phone Number: The phone number of the person submitting the form. This should be the best number to reach the subimtter wether mobile, home, work, or other. Please enter the three-digit area code prefix that is associated with the telephone number and the seven-digit telephone number. For international telephone numbers, please include the country code and city code (routing) codes in front of the actual telephone number..


Submitter Relationship to Patient: What is your relationship to the patient (example, spouse, child, friend, caregiver, etc.)?


Subscriber: The individual who signs and is responsible for a contract with a health insurance plan. The subscriber is the person subcribing to the insurance plan for the patient case. The subscriber is different from the enrollee, who is defined as anyone covered under the contract.


Type of Procedure: Something that is done to fix a health problem or to learn more about it. For example, surgery, tests, and putting in an IV (intravenous line) are procedures.


Type of Outpatient Service: Select the type of procedure you are seeking services for whether you are coming in for inpatient care or outpatient care.


Worker's Compensation: Insurance that employers are required to have to cover employees who get sick or injured on the job while performing job-related duties.


Zip or Postal Code:Enter the zip code. If the zip code is for a U.S. State or Possession, the zip code must be numeric. If the zip code is for a Canadian Province, the zip code must be six characters long and the last character must be a number.