Patient Pre-Registration Information

Please complete the following information for pre-registration prior to services. Please bring your insurance cards with you the day of service for verification. Should you have questions, call our Patient Pre-Registration Department at 419-407-1711. Thank you for choosing Mercy St. Anne Hospital.

The on-line pre-registration should be completed more than 3 days before arrival to the facility in order to complete the registration data base process at the facility.
Patient Information:
*First Name (Legal)
Middle Initial
*Last Name
*Address
*City
*State
*Zip
*County
*Phone Number ( - 
*Social Security #  -  - 
Email Address
*Date of Birth / /
*Marital Status
*Gender
Race
Religion
Church preference
*Employer
*Do you have a Living Will? No    Yes
*If yes,
where is it located?
*Do you have a Durable Power of Attorney? No    Yes
*If no, would you like the forms? No    Yes
*If you have a Living Will or Durable Power of Attorney please bring a copy with you on your day of admission.
*If the patient is under the age of 18, please provide the following information about the parent or guardian who will accompany the child.
Relationship to the patient
First Name
Middle Initial
Last Name
Address
City
State
Zip
 
Emergency Contacts:
*Emergency Contact Name
*Emergency Contact Phone Number ( - 
Relationship to the patient
Secondary Contact Name
Secondary Contact Phone Number ( - 
Relationship to the patient
HIPAA Contact Name
What is HIPAA?
HIPAA Contact Phone Number
What is HIPAA?
( - 
*If married
Spouse's Name
*If married
Spouse's Phone Number
( - 
 
Insurance Information:
*Insurance Name or Workman's Compensation MCO
You will receive a phone call to complete the Medicare required Medicare Secondary Payor Questionnaire.
If the patient does not have insurance please skip to the "Admission Information" section.
Policy Holder Name
Relationship of Policy Holder to Patient
Policy/ID #
Group Number
Insurance Company Billing Address:
Insurance Company Phone Number ( - 
Policy Holder
Date of Birth
/ /
Policy Holder
Social Security #
 -  - 
Employer
Employer Address
Employer City
Employer State
Employer Zip
Employer Phone ( - 
Is this visit due to an injury? No    Yes
Work Related No    Yes
*If yes,
Employer at time of Injury
Auto Accident No    Yes
*If yes,
Date of Accident
/ /
 
Additional Insurance Information:
Insurance Name
Policy Holder Name
Relationship of Policy Holder to Patient
Policy/ID #
Group Number
Insurance Company
Billing Address:
Phone Number ( - 
Policy Holder
Date of Birth
/ /
Policy Holder
Social Security #
 -  - 
Employer
Employer Address
Employer City
Employer State
Employer Zip
Employer Phone ( - 
 
Admission Information:
*Date of
Admission/Testing
/ /
*Reason for
Admission/Visit
Diagnosis
*Ordering Physician
(Specialist, Surgeon, OB/GYN)
Ordering Physician
Address
*Family Doctor
Family Doctor
Address
For Maternity Patients
Expected Delivery Date
/ /