The healthcare journey often begins with a crucial step: completing the Hospital Pre-Registration form. This document, intended for new patients, is more than just paperwork; it's a streamlined way to introduce patients to their care providers while ensuring that all necessary information is ready for their first appointment. Key details such as patient demographics, including name, date of birth, address, social security number, and contact information, lay the foundation for a smooth administrative process. The form also probes how patients learned about the hospital, whether through media, recommendations, or other channels, highlighting the facility's outreach efforts. In emergencies, the form asks for contacts, ensuring that the hospital can quickly reach someone close to the patient if necessary. Employment and guarantor information sections further prepare the hospital and patient for financial arrangements, detailing who is responsible for covering the costs of care. Moreover, the form requires information about primary and secondary insurance to expedite billing and claims. A disclaimer statement towards the end secures consent for the hospital to process claims and confirms the patient's financial responsibilities. This document, therefore, encapsulates crucial patient information, consent for treatment and billing, and a pledge of responsibility, making it an indispensable part of the healthcare process.
| Question | Answer |
|---|---|
| Form Name | Hospital Pre Registration Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | SSN, Subscriber, ragistration, pre |
NEW PATIENT
Please complete and bring at the time of your first appointment.
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Primary Physician: __________________________________________ |
Patient Demographics |
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Name: |
___________________________________________________ Date of Birth: __________________ |
Address: |
___________________________________________________ SSN: _________________________ |
City: |
___________________________________________________ State: __________ Zip: __________ |
Home Phone |
____________________Cell Phone: |
How did you hear about us? __ Radio __TV __Print Ad __Friend __Insurance __Elliot
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In case of an emergency: |
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Contact # 1: ________________________________ |
Contact #2: ________________________________ |
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Relationship: ________________________________ |
Relationship: ________________________________ |
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Home Phone ________________________________ |
Home Phone ________________________________ |
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Employment Information |
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Employer Name: |
____________________________________________ Phone: _________________________ |
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Employer Address: ____________________________________________ City: ___________________________
State: ____________ Zip: ___________ Occupation: _____________________________________
Guarantor Information (person financially responsible)
Name: |
__________________________________________________ Relationship: ____________________ |
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Address: |
__________________________________________________ SSN: ___________________________ |
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City: |
__________________________________________________ State: _________ Zip: _____________ |
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Home Phone |
_______________________ |
Cell Phone: _______________________ |
Employer Name: _______________________________________________ Phone: __________________________
Employer Address: _____________________________________________ City: ____________________________
State: ____________ Zip: _____________
Primary Insurance (please present card for copying)
Subscriber Name: |
_____________________________________________________________________________ |
Date of Birth: |
_____________________ SSN: __________________________ |
Subscriber Employer: ____________________________________________________________________________
Employer Address: _____________________________________________ City: ____________________________
State: ____________ Zip: _____________
Secondary Insurance (please present card for copying)
Subscriber Name: |
______________________________________________________________________________ |
Date of Birth: |
______________________ SSN: ___________________________ |
Subscriber Employer: __________________________________________________________
Employer Address: ____________________________________________ City: _____________________________
State: ____________ Zip: _____________
DISCLAIMER STATEMENT
I authorize Elliot Physician network to submit claims to my insurance carrier and to release any medical information necessary to process all claims. I also authorize payment for any medical benefits to the aforementioned for all services provided until further notified for this account. I agree that I am financially responsible for any
___________________________________________________________________________________________
Patient SignatureDate
___________________________________________________________________________________________________________________
Signature of Responsible Party |
Date |