What influenced your decision to come to Hillcrest?

If other:

First Name:

Middle Name:

Last Name:

Social Security #:

Birth Date:

Home Phone:

May we contact you by mail or email?

Email Address:

Mailing Address 1:

Mailing Address 2:

City:

State:

Zip:

Marital Status:

Race:

Religion:

Church Preference:

Are you employed?

Employer:

Occupation:

Work Phone:

Date:

Services:

Date of Last Menstrual Period (if O.B. service):

Primary Care Physician:

Diagnosis:(Reason for Hospital Visit)

Admitting Physician:

Has Patient ever had services
at Hillcrest Health System?

PLEASE BRING COPY OF INSURANCE CARD(S) UPON REGISTRATION
Has your insurance company been notified of your admission?

IF YOUR INSURANCE HAS A CO-PAY REQUIREMENT TO THE HOSPITAL, PLEASE MAKE THIS PAYMENT AT TIME OF REGISTRATION.

If medicare is your primary insurance, please leave the button below as "No" and continue the form below where it reads "If Patient is on Medicare:

INSURANCE #1 (Primary):

Do you have insurance?

Name of Insurance Company:

Address of Insurance Company:

City:

State:

Zip:

Phone:

Policy Number:

Group Number:

Effective Date:

Name of Employer, if Group Insurance:

Name of Person Employed:

Relationship to Patient:

INSURANCE #2 (Secondary):

Do you have a second insurance?

Name of Insurance Company:

Address of Insurance Company:

City:

State:

Zip:

Phone:

Policy Number:

Group Number:

Effective Date:

Name of Employer, if Group Insurance:

Name of Person Employed:

Relationship to Patient:

Is Patient on Medicare?

Name as it appears on the Medicare Card:

Policy Number:

If retired, date of retirement (required by Medicare):

Does Medicare coverage include Part A?

Effective Date:

Does Medicare coverage include Part B?

Effective Date:

GUARANTOR INFORMATION:

Is patient the guarantor?

First Name:

Middle Name:

Last Name:

Social Security #:

Birth Date:

Home Phone:

Mailing Address 1:

Mailing Address 2:

City:

State:

Zip:

Employer:

Occupation:

Work Phone:

Employer Address 1:

Employer Address 2:

City:

State:

Zip:

SPOUSE INFORMATION:

Is patient the guarantor?

First Name:

Middle Name:

Last Name:

Social Security #:

Birth Date:

Home Phone:

Mailing Address 1:

Mailing Address 2:

City:

State:

Zip:

Employer:

Occupation:

Work Phone:

Employer Address 1:

Employer Address 2:

City:

State:

Zip:

PERSON TO NOTIFY:

Middle Name:

Last Name:

First Name:

Zip:

State:

City:

Mailing Address 2:

Mailing Address 1:

Relationship:

Home Phone:

Work Phone:

NEXT OF KIN (different address/phone number from above person):

Middle Name:

Last Name:

First Name:

Zip:

State:

City:

Mailing Address 2:

Mailing Address 1:

Relationship:

Home Phone:

Work Phone:

LIVING WILL (ADVANCED DIRECTIVE) INFORMATION:

Do you have a Living Will?

If yes, is it filed at Hillcrest?

If it is not filed at Hillcrest, can you bring a copy of it at time of registration for services?

Thank you for taking the time to complete the pre-registration. If you are pre-registering by our internet web site, you will be asked to review and verify your information and sign your registration forms upon your arrival at Hillcrest. We look forward to seeing you at Hillcrest.