Pre-Registration

Pre-Registration

Physician/Service Information
Primary Care Physician's Name
First Name
Last Name
Admitting/Ordering Physician's Name:
First Name
Last Name
Date of Service/Admission:*
Services you are scheduled for:
Other:
Procedure Type:
Location:
Your Information
Are you filling out this form for someone else, if yes please enter your name:
First Name *
Middle Initial
Last Name*
Maiden Name:
Race:*
Date of Birth:*
Religion:
Gender: *
Church Affiliation:
Marital Status *
Social Security: *
Email Address: *
Confirm Email Address *
Address*
Street 1:
Street 2:
 
City:
County:
 
State
Zip Code
Home Phone:
Work Phone:
Alternate Phone:
Your Employer Information
Are you employed?
Are you retired?
Date of retirement *
Employment Status*
Occupation: *
Employer Name: *
Work Phone: *
Employer Address *
Street 1:
Street 2:
 
City:
State
Zip Code
Next of Kin Information
First Name: *
Last Name: *
Address same as patient?
Next of Kin Address *
Street 1:
Street 2:
 
City:
State
Zip Code
Relationship: *
Home Phone: *
Work Phone: *
Alternate Phone:
Emergency Contact
First Name: *
Last Name: *
Address same as patient?
Address same as Next of Kin?
Emergency Contact Address *
Street 1:
Street 2:
 
City:
State
Zip Code
Relationship: *
Home Phone: *
Work Phone: *
Alternate Phone:
Language
Translator needed?
What language? *
Primary Insurance Information
Do you have Insurance?
Primary Insurance Name: *
Effective Date:
Insurance Carrier Address *
Street 1
Street 2
 
City
State
Zip Code
Phone Number: *
Policy Holder Name *
Date of Birth: *
Primary Insurance Relationship to Patient: *
Primary Insurance Policy Number: *
Primary Insurance Group Number *
Primary Insurance Social Security Number: *
Company Name: *
Primary Insurance Employment Status: *
Primary Insurance City: *
Primary Insurance State: *
Secondary Insurance Information
Do you have Insurance?
Secondary Insurance Name: *
Effective Date: *
Insurance Carrier Address *
Street 1
Street 2
 
City
State
Zip Code
Phone Number: *
Policy Holder Name *
Date of Birth: *
Secondary Insurance Relationship to Patient: *
Secondary Insurance Policy Number: *
Secondary Insurance Group Number *
Secondary Insurance Social Security Number: *
Company Name: *
Secondary Insurance Employment Status: *
Secondary Insurance City: *
Secondary Insurance State: *
Guarantor Information (Person Financially Responsible)
Same as patient?
First Name *
Middle Initial
Last Name *
Relationship to Patient: *
Social Security Number: *
Guarantor Carrier Address *
Street 1
Street 2
 
City
State
Zip Code
Home Phone: *
Work Phone: *
Your Condition

Please be aware that if you choose or have chosen FMH to deliver your child, updating your physician and FMH of your insurance coverage can be very important to your care during and after discharge for you and your child. If you have any changes in insurance, please contact FMH, immediately.

Is service(s) related to an accident?
Is accident covered by: *
Date of first symptom: *
Ins. Carrier: *
Ins. Carrier Phone Number: *
Claim Number: *
Date of accident? *
Is the patient pregnant or seeking pregnancy-related services?
What is the date of your last menstrual period? *
Advance Directive

To ensure we honor your wishes, your rights and follow federal regulations, all adult patients are asked questions regarding their advance directives. If you have prepared an advance directive, please bring a copy with you on your date of service.

Do you have an advance directive?

If you would like more information about advance directives, please contact FMH Case Management at 240-566-3547 or Pastoral Services at 240-566-3607.

Feedback Area

Tell us what you think of FMH’s online preregistration and how we can make it better