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Online Patient Pre-Registration


Please fill out the following form at least 5-7 business days in advance of your hospital visit. Pre-registered patients must still report to the hospital admission desk upon arrival.

All items with an asterisk (*)  are required. Mary Lanning Healthcare respects patient privacy and confidentiality and makes every effort to ensure that patient-specific information is secure under all circumstances.

Visit Information

Date of Service: (mm-dd-yyyy) *
Type of Procedure: *
Ordering Physician:

Patient Information

Legal Last Name *
Legal First Name *
MI
Calling Name
Social Security # *
Birthdate (mm-dd-yyyy) *

Age *
Gender *
Phone Number *
Cell Phone Number
Mailing Address *
City *
State *
Zip *
Marital Status *
Ethnicity
Race
Preferred Language
Is this procedure related to an accident or injury? *
Would you like to be contacted regarding our payment options?

Employment Information

Is this procedure related to worker's compensation? *
Current Work Status: *
Employer Name (if applicable)
Phone Number
Address
City
State
Zip

Spouse or Responsible Party Information

Name
Home Phone #
Cell Phone #
Relationship to Patient
Birthdate (mm-dd-yyyy)
Social Security #
Mailing Address
City
State
Zip
Is this person responsible for the patient's insurance during this visit? *

Emergency Contact (Someone other than person listed above)

Name
Home Phone #
Cell Phone #
Relationship to Patient
Birthdate (mm-dd-yyyy)
Mailing Address
City
State
Zip

Insurance Information

Medicare?* -
Medicaid?* -

Primary Insurance

Company Name
Insurance Phone #
Is insurance through employment?
Billing Address
Is insurance plan part of Midlands Choice PPO?
City
State
Zip
Name of policy holder
Birthdate (mm-dd-yyyy)
ID #
Group or Plan #
Claim #

Secondary Insurance

Company Name
Insurance Phone #
Is insurance through employment?
Billing Address
Is insurance plan part of Midlands Choice PPO?
City
State
Zip
Name of policy holder
Birthdate (mm-dd-yyyy)
ID #
Group or Plan #
Claim #

Verification

Please Enter Verification Code Below

verification code

I have elected to electronically submit a completed pre-registration form to Mary Lanning Healthcare through the Mary Lanning Healthcare web site. I agree to do so at my own risk and assume all responsibility for any liability arising from such electronic transmission and from errors or omissions in the data I have provided. I agree to release and hold Mary Lanning Healthcare and its affiliates harmless from any and all liability or cause of action arising from the interception, access or use by a third party of any information submitted electronically by me through this web site and from errors or omissions in the data I have provided. I understand that Mary Lanning Healthcare protects electronically submitted data through secure encryption and that the information I submit electronically as part of the pre-registration process will not be used for any purpose other than pre-registration.