Online Pre Registration Form for McLaren Greater Lansing
This is a secured webpage.


* Indicates required information

Type of Service  *

If Other, please specify:

Date of Service - Use Due Date if Maternity

Section 2:

Ordering Physician *

Family Physician  *

Section 3: Patient Demographic information

Patient Legal Name (last name, first name, MI, Jr. Sr, etc.)  *

Date of Birth *

Permanent Address  *

City *

State *

Zip *

Telephone Number  *

Social Security Number

Gender  *

Race *

Marital Status *

Email Address for pre registration confirmation  *

Are you employed outside the home? *

If not employed put N/A *

Are you retired? *

If retired, your approximate retirement Date?

What company did you retire from?

Religious Preference (optional)

Church Preference (optional)

Emergency Contact Information: 

Emergency contact name *

Relationship *

Mailing Address

Date of Birth

Telephone Number *

Alternative Telephone Number


If patient is a minor, information for responsible party:  
Responsible Party legal name

Responsible Party Date of birth

Responsible Party Permanent address

Responsible Party Telephone number

Responsible Party Social Security Number

Responsible Party Gender

Responsible Party Marital Status

Responsible Party Employer

Section 4: Insurance Information
Name of Primary Insurance:  *

Contract or policy number: *

Group number (if Medicare enter n/a):  *

Policyholder Name:  *

Policyholder date of birth: *

Policy Holder employer:  * 

Insurance address (not required for Medicare or Medicaid):

Insurance telephone number: 

Secondary Insurance Name:

Contract or policy number:

Group Number:

Policy Holder name:

Policy Holder date of birth: 

Policy Holder employer: 

Insurance address (no address required for Medicare or Medicaid)

Insurance telephone number:

Are the services related to an accident or injury?

If accident or injury, what is the date of the accident/injury?

Where did this accident or injury happen?

Are the services payable by workers compensation?

If workers compensation please provide workers comp insurance? Name of Insurance, Claim Number, Adjustor Name and telephone number, and claims mailing address (if available) 

Are the services payable under a liability claim?

Liability Claim Information 

Is the accident or injury:

Section 5: Questions we are required to ask  
If someone calls to verify you are at McLaren Greater Lansing, we will confirm your room number, telephone number and condition (stable, critical, etc.)
You have the right to OPT OUT of the facility directory and have no information disclosed.
By answering no, your name will not be included in the facility directory. That means that you are responsible to inform friends and family members regarding your location in the hospital.
By answering no, if a someone calls or inquires about you at the information desk, we will state "we have no information."
Do you want to be included in the facility directory?

Do you have a Durable Power of Attorney or Advance Directive for health care?

Would you like to receive information on Durable Power of Attorney and Advance Directives?

Do you wish to receive confirmation that your pre registration was processed?  *