Patient Pre-Registration Form

McLaren Northern Michigan Online Patient Pre-Registration Form

To pre-register for your visit to McLaren Northern Michigan, please follow these simple steps:

  1. Complete the form below as completely as possible and submit. If the date should change, or even be cancelled, there is no need to contact the hospital.
  2. Petoskey Patients, on your day of arrival, please check-in at the desk at the hospitals main entrance (across from gift shop). Cheboygan patients, please check in on your day of arrival at the emergency department.
  3. All dates must be entered in mm/dd/yyyy format.
  4. This is a secured webpage.

    *Indicates required information
  
  
  
  
  
  
  
  
  
  
  
  
  
  
   
  
  
  
  
  
  
Appointment Information:

  

  

  
(Last,First) 

  
Patient Information:







 


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.











 

Email is used for patient portal invitation

 






 




 

 



  





  

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

(if you do not have insurance, please write self-pay and put an X in the remaining fields


(if you do not have insurance, please write self-pay and put an X in this field)


(if you do not have insurance, please write self-pay and put an X in the remaining fields)


(if you do not have insurance, please write self-pay and put an X in the remaining fields)


Subscriber/Policyholder Information



 



   
Secondary Insurance Information:




Subscriber/Policyholder Information:
 



 



   
Tertiary Insurance Information:




 Subscriber/Policyholder Information:



 



 
Please confirm with your insurance carrier on authorization or referral requirements for this visit:


Additional Medicare Questions:









Age






Disability







End Stage Kidney Disease (ESRD):






Emergency Contact Information:












If you have any questions, please call our office at 231.487.3445 or toll free at 866.652.0992. We are available Monday thru Friday from 9am to 5pm. Thank you for choosing McLaren Northern Michigan for your healthcare needs. By submitting this form you have pre-registered for your upcoming procedure. Petoskey patients: please make sure to call Scheduling at 231.487.3100 to set up your pre-surgical phone interview. Cheboygan Patients: a nurse will contact you to do your pre-surgical phone interview.