Patient Registration : St. Catherine Hospital

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Patient Registration

Patient Information
Fields marked with an asterisk (*) are required.

* First Name:

Middle Name:

* Last Name:

* Mailing Address:

* City:

* State:

* Zip Code:

* Sex:

* Race:

* DOB:

(MM/DD/YYYY)

* Social Security #:

- -

* Home Phone #:

- -

* Marital Status:

Spouse's Name:

Place of Birth:

* Employed?:

Employer Name:

Employer Address:

City:

State:

Zip Code:

Job Title:

Length of Employment:

Responsible Party Information
Fields marked with an asterisk (*) are required.

If the patient is a minor, then parent or legal guardian is responsible for the bill and the following information must be completed.

* Is the patient the responsible party?

First Name:

Middle Name:

Last Name:

Mailing Address:

City:

State:

Zip Code:

Sex:

Marital Status:

DOB:

(MMDDYYYY)

Social Security #:

- -

Home Phone #:

- -

Place of Birth:

Employed?:

Employer Name:

Employer Address:

City:

State:

Zip Code:

Job Title:

Length of Employment:

Insured Information
Fields marked with an asterisk (* )are required.

*Is the patient the insured?
(Person who carried the insurance)

First Name:

Middle Name:

Last Name:

Mailing Address:

City:

State:

Zip Code:

DOB:

(MMDDYYYY)

Relationship to Patient

Social Security #:

- -

Phone #:

- -

Employer Name:

Employer Phone #:

- -

Employer Address:

City:

State:

Zip Code:

Job Title:

Length of Employment:

Insurance Information
Fields marked with an asterisk (*) are required.

* Primary Insurance Type:

Primary Insurance Company Name:

Group #:

Claims Mailing Address:

City:

State:

Zip Code:

To Verify Insurance Phone #:

- -

Pre cert Phone #:

- -

ID # / Certificate / SS#:
(As shown on insurance card)

Do you have additional insurance?

Additional Insurance Type:

Additional Insurance Company Name:

Group #:

Claims Mailing Address:

City:

State:

Zip Code:

To Verify Insurance Phone #:

- -

Pre cert Phone #:

- -

ID # / Certificate / SS#:
(As shown on insurance card)

Miscellaneous Information
Fields marked with an asterisk (*) are required.

Is this visit the result of an accident?:

Date and time of accident:

Place accident occurred:

Do you have:

Living Will?

Durable Power of Attorney?

Does St. Catherine Hospital have a copyone on file?

* Name of Physician
(First and Last Name)

* Date of Procedure or Service:

(MM/DD/YYYY)

Type of Procedure:

Would you like to receive an acknowledgement when your registration has been completed? Yes No

Your E-mail Address: