Pre-Register | Clark Memorial Hospital

*First Name:
*Last Name:
Middle Initial:
*Address:
*City:
*State:
*Zip Code:
*Phone Number:
Cell Phone:
Email:
*Social Security Number:
*Date of Birth:	/ /
Religion:
Race:
*Gender:	Female Male
*Marital Status:	Single Separated Divorced Widowed Married
*Maiden Name:
Spouse's Name:
Primary Emergency Contact:
*Who to Contact in Case of Emergency?:
*Emergency Contact's Relation to Patient?:
*Emergency Contact's Phone:
Secondary Emergency Contact:
Who to Contact in Case of Emergency?:
Emergency Contact's Relation to Patient?:
Emergency Contact's Phone:
Do you have a living will and/or advanced directive?	Yes No
Does anyone have power of attorney over you?	Yes No
Phone number of power of attorney:
Have you ever been a patient at Clark Memorial Hospital?	Yes No
If yes, under what name?	Same Other
Patient's Employment Information:
*Employment Status:
*Patient's Employer:
If retired, last employer:
Address:
Phone:
City:
State:
Zip Code:
Position/Occupation:
Test or Procedure Information:
*Date of Test or Procedure Scheduled:	/ /
*Time of Test or Procedure Scheduled:	:
*First and last name of physician ordering test or procedure:
*First and last name of Primary Care Physician (if different than ordering physician):
*What test or procedure are you scheduled for?
*Are you allergic to Latex?	Yes No
Patient Accident Information:
*Is this visit to Clark Memorial Hospital due to an injury from an accident?	Yes No If "Yes" please fill out the areas marked with a blue asterisk *
*Accident date:	/ /
*Accident Time:	:
*Was this accident job related?	Yes No Unknown
*Location of accident:	Home Work Other
*Type of accident:
*What happened?
Other comments:

(If you have Medicare, please complete this next section of questions. If not, please click on the Primary Insurance section heading to begin that section.)
*Do you have Medicare?	Yes No If "Yes" please fill out the areas marked with a blue asterisk *
*Do you receive Medicare because of end stage renal disease?	Yes No
*If yes, what is the original date?	/ /
*Do you receive dialysis?	Yes No
*If yes, what is the original date of your first regular dialysis?	/ /
*Do you receive Medicare because of a kidney transplant?	Yes No
*If yes, what is the original date?	/ /
*Is the patient covered by ANY Employer Group Health Plan (EGHP)?	Yes No
*Working Over Age 65: Is the patient and/or spouse CURRENTLY EMPLOYED by an employer of 20 or more employees?	Yes No

(The insurance company that covers the patient through an employer, group health plan or private policy. This information should appear on your insurance card.)
*Insurance Company Name:	Medicare Medicaid Blue Cross Humana United Health Care Liability Worker's Comp Other
*ID or policy #:
*Group #:
*Insurance Claims Mailing Address: (Usually found on the back of the card.)
*City
*State:
*Zip Code:
*Phone:
Policy Holder's Information:
*Policy Holder's Name:
*Policy Holder's Social Security Number:
*Policy Holder's Date of Birth:	/ /
*Relation To Patient:	Self Spouse Parent Step-parent Grandparent Other
*Policy Holder's Employer Name:
*Employer Address:
*Employer Phone Number:

(Any other medical insurance plan that may provide additional coverage.)
Insurance Company Name:	Medicare Medicaid Blue Cross Humana United Health Care Liability Worker's Comp Other
ID or policy #:
Group #:
Insurance Claims Mailing Address: (Usually found on the back of the card.)
City
State:
Zip Code:
Phone:
Policy Holder's Information:
Policy Holder's Name:
Policy Holder's Social Security Number:
Policy Holder's Date of Birth:	/ /
Relation To Patient:	Self Spouse Parent Step-parent Grandparent Other
Policy Holder's Employer Name:
Employer Address:
Employer Phone Number:

*Please enter your initials to acknowledge that you have read and understood the Clark Memorial Hospital Notice of Privacy Practices:

How can we help you today?

Patient Pre-Registration

Patient Information

Medicare Payer Questionnaire

Primary Insurance

Secondary Insurance

Notice of Privacy Practices

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