Hospital Patient Pre-Registration


PLEASE NOTE:

This secure form utilizes SSL encryption technology to protect your personal information. Users may be asked to accept a security certificate for this application. Select 'yes' to view the application.

About SSL Certificates

Appointment Information:
Appointment Date: *

  
Appointment Time: *

 :   
Reason for appointment/visit: *
Patient Information:
Patient's first name: *
Patient's middle name:
Patient's last name: *
Maiden/Other name:
Date of birth: *
SSN:
Sex:
Race:
Do you consider yourself to be of hispanic / latino culture?
Yes No
Home Address: *
City: *
State:
Zip: *
Primary Phone: *
 
 
Secondary Phone:
Martial Status:
Religous Affiliation:
Email:
Church:
Patient Employer Information:
Employment Status:
 
 
Employer:
Occupation:
City:
State:
Zip:
Phone:
Emergency Contact Information:
First Name: *
Middle Name:
Last Name: *
Address:
City:
State:
Zip:
Primary Phone: *
Relationship to Patient:
Secondary Phone:
 
 
Emergency Contact Information:
First Name:
Middle Name:
Last Name:
Address:
City:
State:
Zip:
Primary Phone:
Relationship to Patient:
Work Phone:
 
 
Accident Information
Is visit related to an accident or injury?
If yes, briefly describe what caused the accident and how it happened.
Is accident work related?

If yes, enter worker's comp info

Date of accident:
Time:
Do you want the employers billed directly?
If no, do you have worker's compensation?
If yes, list the name of Work Comp Carrier:
Authorization #:
Address:
City:
State:
Zip:
Responsible Party Information
First Name: *
Middle Name:
Last Name: *
Address: *
City: *
State:
Zip: *
Phone:
Social Security #:
Employer:
Employer Phone:
Relationship to Patient:
Physician Information
Primary Care Doctor:
Additional Information
Additional information that may be helpful:
Do you have Advanced Directive?
If yes, is it on file at Bellin Health?
If not, please bring a copy with you if you have one completed.
Is it ok that your name appear on our patient directory?
Yes No
Confidential Patient Status
1. Bellin Staff will not acknowledge that you are here with visitors and phone calls.
2. Patients will not receive mail or deliveries.
3. Patients may share their hospital information at their discretion.
Per the above of confidential status, do you wish to be a confidential patient during your visit at Bellin Hospital?
Yes No
Primary Insurance Information
Primary Insurance:
If your insurance carrier does not appear in the list, please enter it here:
Address:
City:
State:
Zip:
Phone:
Policy Number:
Group Number:
Name of person in your family that carries the insurance (Subscriber):
Subscribers Relationship to Patient:
Subscriber's Date of Birth:
Subscriber's Social Security #:
Employment Status:
Is insurance through present or former employer?
Subscriber's Employer Name:
Are you aware of any Network associated with your insurance company? If yes, please select from the list.
Other Network
 
 
Secondary Insurance (if applicable)
Secondary Insurance:
If your insurance carrier does not appear in the list, please enter it here:
Address:
City:
State:
Zip:
Phone:
Policy Number:
Group Number:
Name of person in your family that carries the insurance (Subscriber)::
Subscribers Relationship to Patient:
Subscriber's Date of Birth:
Subscriber's Social Security #:
Employment Status:
Is insurance through present or former employer?
If former employer, Employer's Name:
Are you aware of any Network associated with your insurance company? If yes, please select from the list.
Other Network: