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Online Patient Pre-Registration


Notice This form is for hospital patient registration only.

If you wish to register for the Health Fair, please click the Health Fair link with the star at the top of the page.

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.