Maternity Pre Registration Form PDF Details

When expecting a new arrival, preparation is key, and this includes handling necessary paperwork like the Maternity Pre-Registration Form. This comprehensive form collects essential information from expectant mothers to ensure a smooth registration process and hospital experience. Required details include the patient's name, date of birth, social security number, address, phone number, marital status, smoking status, religious preference, and the name of their church if applicable. Additionally, it entails providing the expected delivery date and details about healthcare providers including the obstetrician, gynecologist, infant physician, and primary care physician. Employment information for both the patient and spouse or next of kin is also required, alongside a detailed insurance section that includes information on primary and secondary coverage. This form also encourages the addition of the newborn to the patient’s insurance policy post-birth and offers guidance for those needing financial assistance with hospital expenses. Not only does this form gather vital patient information, but it also serves as a reminder to ensure all insurance matters are in order before the baby’s arrival, emphasizing the need to pre-select a pediatrician or family physician from the hospital's approved list. Completing and submitting this form, along with photocopies of insurance cards and photo ID, facilitates a more focused and stress-free hospital experience, letting families concentrate on the excitement of their new addition.

QuestionAnswer
Form NameMaternity Pre Registration Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesALEUT, photocopy, Obstetrician, pre

Form Preview Example

Maternity Pre-Registration Form

Patient Information

Patient’s Last Name (as listed on photo ID)

First Legal Name

 

MI

 

Date of Birth

 

Age

 

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

City

 

 

 

 

State

 

Zip

 

Home Phone Number

 

 

 

 

 

 

 

 

 

 

 

Marital Status

Do you smoke?

Religious Preference

 

Name of Church

 

 

Official Estimated Delivery Date (NOT date of scheduled procedure)

 

 

 

 

 

 

 

 

 

Physician/Obstetrician/Gynecologist/(If Nurse Midwife, give sponsoring Dr. Name)

 

Infant Physician (if known at time registration sent) Must be OPRMC physician*

Primary Care Physician

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Employer

 

 

 

 

 

 

 

 

 

 

Occupation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Street Address

 

 

 

City

 

 

 

 

State

 

Zip

 

Employer Phone Number

 

 

 

 

 

 

 

 

 

 

Race (please check the one that most accurately describes your race):

ASIAN/PACIFIC ISLANDER

ASIAN INDIAN

BLACK/AFRICAN AMERICAN

HISPANIC/SPANISH/LATIN

HISPANIC-AFRICAN AMER ANCESTRY

NATIVE AMERICAN/ALASKAN/ALEUT

MULTI-RACIAL

OTHER

 

UNKNOWN

WHITE/CAUCASIAN

WEST INDIAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse, Next of Kin or Insurance Cardholder Information (if different than patient)

Last Name

 

First Legal Name

 

MI

 

Date of Birth

 

Age

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address (If different than above)

 

 

 

 

City

 

 

 

State

Zip

Home Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse/Next of Kin Employer

 

 

 

 

 

 

 

 

 

Occupation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Street Address

 

 

 

 

City

 

 

 

State

Zip

Employer Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Emergency Contact (other than Spouse/Next of Kin)

 

 

Home Phone

 

 

 

 

Work Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Relationship to Primary Insurance Cardholder (circle one)

 

 

 

 

 

 

 

 

 

 

 

 

Self

Spouse

Other (please specify - parent, guardian, etc.):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Insurance company name

 

 

 

Insurance Address

 

 

 

 

City

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

Insurance Phone Number

 

Policy/Certificate/ID Number

 

 

Group Number

 

Relationship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Secondary Insurance company

 

 

 

Insurance Address

 

 

 

 

City

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

Insurance Phone Number

 

Policy/Certificate/ID Number

 

 

Group Number

 

Relationship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*See “Before Your Baby Arrives - Find a pediatrician or family physician”

REMEMBER:

•Please send a photocopy of all your insurance cards and a copy of your photo ID (driver’s license, passport).

•Please remember to add your baby to the appropriate insurance policy after the baby is born.

•If you anticipate having any difficulty in paying your portion of your hospital expenses, please call the Hospital Business Office

•for assistance. For last name A-L call 913-541-5321; M-Z call 913-541-5887.

•If your envelope is missing you may mail to: Maternity PreAdmission, Overland Park Regional Medical Center, 10500 Quivira Road, Overland Park, KS 66215 or if you prefer it can be e-mailed to oprm.babies@hcahealthcare.com.

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