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Online Pre-Registration
  1. Patient Information
  2. Last Name(*)
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  3. First Name(*)
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  4. Middle Name
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  5. Maiden Name
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  6. Gender(*)
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  7. Marital Status(*)
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  8. Date of Birth(*)
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  9. Birth Place: County/State
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  10. Social Security Number(*)
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  11. Street Address(*)
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  12. City(*)
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  13. State(*)
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  14. Zip Code(*)
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  15. County
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  16. Home Telephone(*)
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  17. E-Mail Address
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  18. Employer
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  19. Patient Occupation
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  20. Employer Address
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  21. Employer's Phone Number
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  22. Responsible Person: (GUARANTOR) The person responsible for any portion of the hospital bill not covered by insurance.
  23. Last Name(*)
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  24. First Name(*)
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  25. Middle Name
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  26. Street Address(*)
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  27. City(*)
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  28. State
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  29. Zip Code(*)
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  30. Phone(*)
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  31. Relationship to Patient(*)
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  32. Responsible Party SSN
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  33. Responsible Person's Employer
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  34. Occupation
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  35. Employer's Phone Number
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  36. Employer's Street Address
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  37. Emergency Addressee: In event of emergency whom should we notify other than spouse or responsible party.
  38. Last Name
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  39. First Name
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  40. Middle Name
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  41. Street Address
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  42. City
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  43. State
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  44. Zip Code
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  45. Phome
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  46. Relationship to Patient
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  47. Emergency Person's Employer
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  48. Employer's Phone Number
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  49. Employer's Street Address
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  50. Registration Information.
  51. Expected Date of Registration
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  52. Being hospitalized for?
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  53. Accident Information
  54. Is this hospitialization the result of an accident?
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  55. Where did the accident occur?
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  56. Name of individual's residence or name of organization where accident occured.
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  57. Address of Accident
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  58. Date of Accident
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  59. Name of person to contact concerning accident.
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  60. Insurance and other sources of payment. NOTE: ANY DEDUCTIBLE AMOUNTS ARE PAYABLE AT Registration
  61. Blue Cross / Blue Shield
  62. Contract Number
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  63. Group Number
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  64. Effective Date
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  65. Policy Holder Name
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  66. Subscriber's SSN
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  67. State Issued
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  68. Medicare Health Insurance: If you have medicare, please answer the following questions.
  69. Medicare claim number
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  70. Name as listed on Medicare Card
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  71. Group Insurance: (Other than Blue Cross) carried through employer, union or association.
  72. Name of Insurance Carrier
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  73. Insured SSN
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  74. Relationship to patient
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  75. In whose name is the insurance carried?
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  76. Name of employer through which insurance is carried?
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  77. Phone Number
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  78. Group Policy Number
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  79. Certificate Number
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  80. Medicaid Information: (Must present current monthly card on Registration).
  81. Name of individual card issued
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  82. Medicaid number including suffix number
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  83. Individual hospital insurance (other than Blue Cross). Premium paid directly to insurance company.
  84. Name of Insurance Company
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  85. Name of Insured Person
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  86. Policy Number
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  87. Policy Issue Date
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  88. Champus Information Active or retired personnel wishing to file on Champus must furnish a non-availability statement for any scheduled admission. You will also need to present your military identification on admission to the hospital.
  89. Sponsor's Name
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  90. Sponsor's SSN
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  91. Status
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  92. Military Address for Active Duty Personnel
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  93. Relationship to Patient
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  94. Card Number
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  95. Issue Date
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  96. Expiration Date
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