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Registration Form

Please fill out the following form at least three business days in advance of your hospital visit. Pre-registered patients must still report to the hospital admission desk upon arrival.

All items with an asterisk (*)  are required. Memorial Community Health respects patient privacy and confidentiality and makes every effort to ensure that patient-specific information is secure under all circumstances.

Visit Information

Date of Service: *
Reason for Visit: *
Admitting MD:

Patient Data

Legal Last Name *
Legal First Name *
MI
Previous Last Name

Social Security Number *
Birthdate (MM-DD-YYYY) *

Age *
Marital Status *
Ethnicity



Race






Preferred Language



Phone Number *
Mailing Address *
City *
State *
Zip *
Employer Name
Address
Phone Number

Spouse or Responsible Party Information

Name
Home Phone #
Relationship to Patient
Mailing Address
City
State
Zip
Birthdate (MM-DD-YYYY)
Social Security Number
Employer
Employer Phone #
Employer Address
City
State
Zip

Next of Kin (Someone other than person listed above)

Name
Home Phone #
Relationship
Mailing Address
City
State
Zip

Insurance Information

Medicare? If Yes, Number:
Medicaid? If Yes, Number:

Primary Insurance Company Name
ID #
Group or Plan #
Insurance Phone #
Is pre-certification required?
Name of policy holder
Is insurance through employment?
Secondary Insurance Company Name
ID #
Group or Plan #
Insurance Phone #
Is precertification required?
Name of policy holder
Is insurance through employment?

verification code

I have elected to electronically submit a completed pre-registration form to Memorial Community Health, Inc. through the Memorial Community Health web site. I agree to do so at my own risk and assume all responsibility for any liability arising from such electronic transmission and from errors or omissions in the data I have provided. I agree to release and hold Memorial Community Health, Inc. and its affiliates harmless from any and all liability or cause of action arising from the interception, access or use by a third party of any information submitted electronically by me through this web site and from errors or omissions in the data I have provided. I understand that Memorial Community Health protects electronically submitted data through secure encryption and that the information I submit electronically as part of the pre-registration process will not be used for any purpose other than pre-registration.