Pre-Registration

pre-registration

Patients

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Emanuel Medical Center's recently launched website is now offering convenient on-line pre-registration for all outpatient and inpatient services. Pre-registration is designed to help speed processing and decrease wait time on the day of the visit. All patients who pre-register must still report to Central Registration to complete the process and sign required documents

EMANUEL MEDICAL CENTER
On-Line Pre-Registration

	Indicates a Required Field

Patient Information


	Last Name
	First Name
	Middle Initial
	Previous or Maiden Name
	Social Security Number
	Date of Birth
	Address #1
	Address #2
	City
	State
	Zip
	Telephone #1
	Best time to call
	Telephone #2
	Best time to call
	E-Mail Address
	Race
	Sex	Male Female

	Marital Status


	Is the patient under 18 or does the patient have a court appointed guardian or guarantor ? Yes No

	Is Patient Currently Employed ? Yes No

Patient – Employment Information


Occupation / Job Title
Employer
Address #1
Address #2
City
State
Zip

Best Time to Call


May we contact your supervisor?		Yes No

Guardian / Guarantor – General Information


	Same as Patient?	Yes No
	Last Name
	First Name
	Middle Initial
	Previous or Maiden Name
	Relationship to the Patient
	Social Security Number
	Date of Birth
	Address #1
	Address #2
	City
	State
	Zip
	Telephone #1
	Best time to call
	Telephone #2
	Best time to call
	E-mail Address


	Is the Guardian or Guarantor Currently Employed Yes No

Guardian / Guarantor – Employment Information


	Occupation / Job Title
	Employer
	Address #1
	Address #2
	City
	State
	Zip
	Telephone

Primary Insurance


	Insured / Subscriber's Name (As It Appears on Card)
	Insured / Subscriber's Relationship to Patient
	Certificate / S.S #
	Group Number
	Insurance Co. Name / Carrier
	Insurance Co. Address 1
	Insurance co. Address 2
	Insurance Co Member Servers Telephone Number
	Employer that issued the policy
	Facility Authoriazation


	Comments

Secondary Insurance


	Insured / Subscriber's Name (As It Appears on Card)
	Insured / Subscriber's Relationship to Patient
	Insured / Subscriber's Date of Birth
	Certificate / S.S #
	Group Number
	Insurance Co. Name / Carrier
	Insurance Co. Address 1
	Insurance Co Address 2
	Insurance Co Member Servers Telephone Number
	Employer that issued the policy
	Facility Authorization


	Comments

Additional Insurance


	Insured / Subscriber's Name (As It Appears On Card)
	Insured / Subscriber's Relationship to Patient
	Insured / Subscriber's Date of Birth
	Certificate / S.S #
	Group Number
	Insurance Co. Name / Carrier
	Insurance Co. Address 1
	Insurance Co Address 2
	Insurance Co Member Servers Telephone Number
	Employer that issued the policy
	Facility Authorization


	Comments

Admission / Appointment Information


	Admission / Appointment Reason (Please List the Date of the Onset of the Illness/Injury)
	Admission / Appointment Location
	Admission / Appointment Date
	Admission / Appointment Time
	Admitting / Ordering Physician's Name
	Sugery Date
	Surgeon's Name


	If necessary¸ can a registration representative contact you by Phone? Yes No


	Telephone
	Best time to Call / Other Comments


	If necessary¸ can a registration representative contact you by e-mail? Yes No


	E-mail Address


	Have you been a patient here before ?	Yes No
	Do you have outstanding accounts with us ?	Yes No
	Would you like to be contacted by a financial counselor?	Yes No
	Is this a Maternity related visit ?	Yes No


	Please list your last menstrual period.

Additional Emergency Contact – Parent or Nearest Realtive


	Full Name
	Relation to Patient or Guardian
	Address #1
	Address #2
	City
	State
	Zip
	Home / Evening Phone Number
	Daytime Phone Number


	Comments

EMANUEL MEDICAL CENTER On-Line Pre-Registration

EMANUEL MEDICAL CENTER
On-Line Pre-Registration