Online Patient Pre-Registration Form - McLaren Northern Michigan

McLaren Northern Michigan Online Patient Pre-Registration Form

* Indicates required information

Appointment Information:

Date of Procedures: *

Location of Procedures: *

Order Physician: *

Procedure/Test to be Performed: *

Patient Information:

Patient Last Name: *

Patient First Name: *

Patient Middle Initial:

Suffix:

Date of Birth: *

Age: *

Sex: *

Social Security Number:

Reason for not providing Social Security Number:

Note: if you do not provide your SSN, your Mother’s Maiden Name will be required.

Street Address: *

City: *

State: *

Zip Code: *

Mailing Address (if different than above):

City:

State:

Zip Code:

Primary Phone: *

Secondary Phone:

Work Phone:

Email Address: * Email is used for patient portal invitation

Marital Status: *

Patient Mother’s Maiden Name:

State You Were Born In:

Race:

Ethnic Origin:

Religious Preference:

Employer Status: *

Name of Employer:

Employer Address:

Employer Phone:

May the hospital acknowledge you to family & friends? *

May the hospital acknowledge to clergy? *

Is this visit due to an accident? *

If yes, what type of accident?

Date of Accident:

Time of Accident:

State in which accident occurred:

Is no-fault insurance available?

Is liability insurance available?

Primary Care Physician (if seen past 18 months):

If registering a minor, please provide your First & Last Name and DOB:

What is your relationship to the patient? *

Insurance Information:

Primary Insurance – Workman's Comp/Auto Insurance (Please enter numbers as they appear on the card):

Insurance Company Name: *

Contract/Policy/Recipient Number: *

Group/Issuer Number: *

Name on Card: *

For work comp claims: specialist name & phone (if provided):

Subscriber/Policyholder Information:

Last Name:

First Name:

Date of Birth:

Relationship to Patient:

Secondary Insurance Information:

Insurance Company Name:

Contract/Policy/Recipient Number:

Group/Issuer Number:

Name on Card:

Subscriber/Policyholder Information:

Last Name:

First Name:

Middle Initial:

Date of Birth:

Social Security Number:

Relationship to Patient:

Tertiary Insurance Information:

Insurance Company Name:

Contract/Policy/Recipient Number:

Group/Issuer Number:

Name on Card:

Subscriber/Policyholder Information:

Last Name:

First Name:

Middle Initial:

Date of Birth:

Social Security Number:

Relationship to Patient:

Authorization – Referral Number:

Are any of the above plans Medicare? *

Additional Medicare Questions

Gov’t Research Agency Pay? *

VA Authorized? *

Black Lung Benefits? *

Black Lung Benefits Start Date:

Are you receiving Medicare as the result of: *

Medicare – Age Details

Is Patient still working?

If yes, GHP coverage & ≥100 employees?

If no, Patient retirement date:

Is spouse employed?

If yes, GHP coverage & ≥100 employees?

Spouse Name:

Medicare – Disability Details

Disability Start Date:

Is patient still working?

If yes, GHP coverage & ≥100 employees?

If no, Patient retirement date:

Is spouse employed?

If yes, GHP coverage & ≥100 employees?

Spouse Name (Last, First):

End Stage Kidney Disease (ESRD) Details

If yes, GHP coverage?

If yes, received transplant?

If yes, date of transplant:

If yes, receive maintenance dialysis?

If yes, dialysis began:

Within 30-month coordination period?

Emergency Contact Information

Emergency Contact: *

Relationship to Patient: *

Primary Phone: *

Alternate Phone:

Emergency Contact Address:

Alternate Emergency Contact:

Relationship to Patient:

Primary Phone:

Alternate Phone:

Alternate Contact Address:

Questions or Comments

Questions or Comments:

If you have questions, please call our office at 231-487-3445 or toll free at 866-652-0992 Monday – Friday from 9 am until 1 pm; between 1 – 5 pm, call 231-487-5525. Thank you for choosing McLaren Northern Michigan for your healthcare needs.

By submitting this form you have pre-registered for your upcoming procedure.

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