Online Patient Pre-Registration Form - McLaren Northern Michigan | McLaren Northern Michigan Documents and Links

Appointment Information:
McLaren Northern Michigan Online Patient Pre-Registration Form To pre-register for your visit to McLaren Northern Michigan, please follow these simple steps: Complete the form below as completely as possible and submit. If your appointment date should change, or even be canceled, there is no need to contact the hospital. On the day of your appointment, please enter the facility based on the campus, service and time you are coming: Petoskey Campus Surgery - come to the Surgery Entrance off of Connable Medical Imaging or Lab Test - come to the Main Entrance off of Jackson Street Cheboygan Campus Surgery - come to the Emergency Entrance before 6:30 am; the Medical Office Building Entrance after 6:30 am Lab Tests - come to the Medical Office Building Entrance Medical Imaging Test - come to the Emergency Entrance All dates must be entered in mm/dd/yyyy format. This is a secured webpage. *Indicates required information
Date of Procedures: *	Location of Procedures: *	Order Physician: * (Last,First)	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: please note:: if you do not provide your social security number, your Mothers Maiden Name will be required. This is for your safety and to secure your identity.
Street Address: *	City: *	State: *	Zip Code: *
Mailing Address (if different than above):	City:	State:	Zip Code: *
Primary Phone: *	Secondary Phone:	Work Phone
Email: Email is used for patient portal invitation
Marital Status: *	Patient Mothers 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 are a patient to family and friends, in the event you were to stay overnight in the hospital? *		May the hospital acknowledge to clergy that you are here as a patient? *
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?	Please provide the name of you Primary Care Physician (only if you have seen him/her in the past 18 months. Please list first name, last name & location of practice):	If you are a parent/guardian completing this registration for a minor (age 17 or younger), please provide your first and last name and your Date of Birth:	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: * (if you do not have insurance, please write self-pay and put an X in the remaining fields	Contract Number - Policy Number - Recipient Number: * (if you do not have insurance, please write self-pay and put an X in this field)	Group - Issuer Number * (if you do not have insurance, please write self-pay and put an X in the remaining fields)	Name - as it appears on card: * (if you do not have insurance, please write self-pay and put an X in the remaining fields)
For work comp claim please provide specialist name and phone number if one has been provided: *
Subscriber/Policyholder Information
Last Name:	First Name:	Middle Initial:
Date of Birth:	Social Security Number:	Relationship to Patient:
Secondary Insurance Information:
Insurance Company Name: *	Contract Number - Policy Number - Recipient Number: *	Group - Issuer Number *	Name - as it appears 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 Number - Policy Number - Recipient Number: *	Group - Issuer Number: *	Name - as it appears on card: *
Subscriber/Policyholder Information:
Last Name:	First Name:	Middle Initial:
Date of Birth:	Social Security Number:	Relationship to Patient:
Please confirm with your insurance carrier on authorization or referral requirements for this visit:		Authorization - Referral Number:
Are any of the above plans Medicare? *

Additional Medicare Questions:
Are services to be paid by a government research agency? *	Has Veterans Affairs authorized and agreed to pay for care? *	Does the patient receive black lung benefits? *	If you are receiving black lung benefits, date benefits began:
Are you receiving Medicare as the result of: *

Age
Is Patient still working?	If yes, do you have a GHP - General Health Plan - and employ 100 employees?	If no, Patient retirement date:
Is spouse employed?	If yes, do you have a GHP - General Health Plan - and employ 100 employees?	Spouse Name:

Disability
If yes, date of disability:	Is patient still working?	If yes, do you have a GHP - General Health Plan - and employ over 100 employees?	If no, Patient retirement date:
Is spouse employed?	If yes, do you have a GHP - General Health Plan - and employ 100 employees?	Spouse Name (last, first):

End Stage Kidney Disease (ESRD):
If yes, do you have GHP - General Health Plan - coverage?	If yes, have you received a kidney transplant?	If yes, date of transplant:
If yes, do you receive maintenance dialysis?	If yes, date dailysis began:	If yes, within the 30-month coordination period?

Emergency Contact Information:
Emergency Contact: *	Relationship to Patient: *	Primary Phone: *	Alternate Phone:
Emergency Contact Address:
Alternate Emergency Contact:	Relatioinship to Patient:	Primary Phone:	Alternate Phone:
Emergency Contact Address:
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.

Online Patient Pre-Registration Form - McLaren Northern Michigan

McLaren Northern Michigan Online Patient Pre-Registration Form