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 877-352-7149. Thank you for choosing Humility of Mary Health Partners.
 
* denotes information that is required.
Patient Information:
* Patient Name    
* Address    
* City    
* State    
* Zip    
* Phone Number     ( )
E-mail Address    
* Social Security Number    
* Date of Birth    
Race/Ethnicity    
Marital Status    
 
Employment Status:
* Is the patient currently  
employed?  
  Yes No
If yes, please complete the remainder of this section.
Occupation    
Employer Name    
Address    
City    
State    
Zip    
Phone    ( )
 
Nearest Relative:
* First Name    
* Last Name    
* Relationship    
Address    
* City    
* State    
Zip    
* Phone    ( )
 
Holder of Insurance Policy:
* Is the patient also the  
insurance holder?  
  Yes No
* Policyholder Name    
* Address    
* City    
* State    
* Zip    
* Phone Number    ( )
E-mail Address    
* Social Security Number    
* Date of Birth    
* Is the policyholder currently  
employed?  
  Yes No
Occupation    
Employer Name    
Address    
City    
State    
Zip    
Phone    ( )
 
Primary Insurance Information:
If you use Medicare, an admission financial representative will contact you for additional information.
* Does the patient have  
primary insurance?  
  Yes No
If yes, please complete the remainder of this section.
If no, please provide additional   payment information    
Insurance Company Name    
Group Number     
Policy Number    
Billing Address    
City    
State    
Zip    
Customer Service Number    ( ) 
 
Secondary Insurance Information:
* Does the patient have  
secondary insurance?  
  Yes No
If yes, please complete the remainder of this section.
Insurance Company Name    
Group Number     
Policy Number    
Billing Address    
City    
State    
Zip    
Customer Service Number    ( ) 
 
Admission Information:
Ordering Physician    
Test being performed    
* Is this visit due  
to an accident or injury?  
  Yes No
If yes, an admission financial representative will contact you for additional information.
Diagnosis on Order    
Family Physician Name    
* Expected Date of Service    
* Service Facility    
 
Other Information:
* Are you a smoker?     Yes No
* Do you have an Advance  
Directive (Power of  
Attorney/Living Will)?  
  Yes No
 
Please review all information carefully before submitting this form.