Online Pre-Registration

Register for Your McLaren Northern Michigan Appointment

McLaren Northern Michigan is committed to making patient registration as easy and efficient as possible. If you are scheduled for a procedure or test, you may pre-register by using our online registration form. This form must be completed and submitted at least 24 hours prior to your scheduled appointment.

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. A confirmation will be emailed to you for your records. 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.

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.

Captcha: *

McLaren Health Care Search

Online Pre-Registration

Register for Your McLaren Northern Michigan Appointment

McLaren Northern Michigan Online Patient Pre-Registration Form

Appointment Information:

Patient Information:

Insurance Information:

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

Subscriber/Policyholder Information:

Secondary Insurance Information:

Subscriber/Policyholder Information:

Tertiary Insurance Information:

Subscriber/Policyholder Information:

Additional Medicare Questions

Medicare – Age Details

Medicare – Disability Details

End Stage Kidney Disease (ESRD) Details

Emergency Contact Information

Questions or Comments