Pre-Registration

Pre-Registration

Physician/Service Information
Date of Service/Admission:
Services you are scheduled for:*

Other:
Primary Care Physician's Name*
First Name
Last Name
Admitting/Ordering Physician's Name:*
First Name
Last Name
Location:*
Patient Information
First Name *
Middle Initial
Last Name*
Maiden Name:
Date of Birth:*
Gender: *
Marital Status *
Social Security:
Email Address: *
Address*
Street 1:
Street 2:
 
City:
County:
 
State
Zip Code
Primary Phone:
Alternate Phone:
Your Employer Information
Are you employed?
Employer Name: *
Work Phone: *
Employer Address *
Street 1:
Street 2:
 
City:
State
Zip Code
Date of retirement *
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: *
Primary Phone: *
Alternate Phone:
Notify In Case Of Emergency
Same as Next of Kin?
First Name: *
Last Name: *
Emergency Contact Address *
Street 1:
Street 2:
 
City:
State
Zip Code
Relationship: *
Primary Phone: *
Alternate Phone:
Language
Interpreter needed?
What language? *
Guarantor Information (Person Financially Responsible)
Same as patient?
First Name *
Middle Initial
Last Name *
Relationship to Patient: *
Social Security Number: *
Same address as patient?
Guarantor Carrier Address *
Street 1
Street 2
 
City
State
Zip Code
Primary Phone: *
Alternate Phone: *
Insurance Information
Does the Patient currently have Insurance?
FMH offers Financial Assistance to patients who qualify. See FMH website for more information.
Insurance Company Name: *
Primary Policy Number: *
Primary Group Number *
Customer Service Phone Number: *
Insurance Carrier Address *
Street 1
Street 2
 
City
State
Zip Code
Insured Name *
Primary Subscriber's Social Security Number: *
Subscriber's Date of Birth: *
Primary Insurance Relationship to Patient: *
Additional Insurance Information
Does the Patient have additional insurance?
Insurance Company Name: *
Policy Number: *
Group Number *
Customer Service Phone Number: *
Insurance Carrier Address *
Street 1
Street 2
 
City
State
Zip Code
Insured Name *
Subscriber's Social Security Number: *
Subscriber's Date of Birth: *
Relationship to Patient: *
Additional Information

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.

What is the date of your last menstrual period? * Mentrual Period Date is Required
Is service(s) related to an accident?
Accident Type: *
Date of first symptom: *
Ins. Carrier: *
Ins. Carrier Phone Number: *
Claim Number: *
Date of accident? *
Additional Comments:

You may receive a call from one of our Customer Service Agents for additional information if necessary.
On the day of your procedure please bring:

  • Photo ID
  • Insurance Card(s)
  • Physician’s Order
  • Payment/Co‐pay/Co‐insurance
FMH offers Financial Assistance to patients who qualify. Find out more information here

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.