Pre-Registration Form

Patient Pre-Registration Form
* Indicates a required field
Date of Service:	(mm/dd/yyyy)	Time:	(hh:mm)
If Pregnant, Due Date:	(mm/dd/yyyy)
Ordering Physician:		Appointment Type:

Patient Information
Last Name:		Middle:
First Name:		Prior Legal Name:
Gender:	Male Female Unknown
Street Address:
City:
State:
Zip:
Home Phone:
Birth Date:
Age:
Social Security Number:

Marital Status:	Single Married Widowed Divorced Seperated	Race:	White Black American Indian Asian Bi-Racial Hispanic Other
Have you ever been treated at Good Samaritan Hospital?:	Yes No
Religious Preference:
Employer Name:		Patient Occupation:
Employer Address:
Employer Phone:	(xxx-xxx-xxxx)
Employment Status:	Full Time Part Time Self Employed Retired Student Unemployed Not Employed Military Active Duty

Nearest Relative/Emergency Contact
Name of Relative: (if married, list spouse)		Relationship to Patient:
Contact Information:
Same as Patient:
Street Address:
City:
State:
Zip:
Home Phone:	(xxx-xxx-xxxx)
Other Phone:	(xxx-xxx-xxxx)

Patient Insurance Information
Insurance:	Yes No
Medicare Information:	Yes No
Coverage Based on:	Age Disability ESRD
Medicare Number as Printed on Card:
Part A Coverage:	Yes No	Part B Coverage:	Yes No
Patient Retirement Date:		Spouse's Retirement Date:
Insurance Information 1	Yes No
Insurance Company Name:
Billing Address:
City
State:
Zip:
Phone Number:
Insured's Name: (if married, list spouse)		Insured's Date of Birth
Insured's Relationship to Patient:		Insured's Social Security #:
Policy/ID Number:		Claim Number:
Group Name: (Employer)		Group Number:
Insured Employment Status:	Full Time Part Time Self Employed Retired Student Unemployed Not Employed Military Active Duty
Insurance Information 2	Yes No
Insurance Company Name:
Billing Address:
City:
State:
Zip:
Phone Number:
Insured's Name: (if married, list spouse)		Insured's Date of Birth:
Insured's Relationship to Patient:		Insured's Social Security #:
Policy/ID Number:		Claim Number: (if applicable)
Group Name: (Employer)		Group Number:
Insured Employment Status:	Full Time Part Time Self Employed Retired Student Unemployed Not Employed Military Active Duty
Medicaid Information	Nebraska Other		(Please specify other)
Name as it appears on card:
Medicaid Number as it appears on card:		Effective Date:	(mm/dd/yyyy)
Managed Care:	Yes No
Name of managed care plan:		PCP:



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