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St. Mary's Good Samaritan
On-Line Pre-Admission
Current Security level:

If you are scheduled for a procedure at the hospital, the speed of the registration process will be greatly enhanced if we can obtain complete and accurate information prior to your arrival. To serve you better, we offer on-line pre-registration for scheduled surgical patients and expectant mothers who will be delivering at one of our hospitals. Our on-line pre-registration process requires you to provide standard registration information. You will need to refer to your insurance card and physician order. It is recommended that you verify your insurance benefits prior to the completion of this form. Please be prepared to present your most current insurance card when you arrive at the hospital.

You can rest assured that our on-line pre-registration process is set up with a secure connection. This allows St. Mary’s Good Samaritan to protect your personal information. After the security alert appears, please click "OK to proceed".

If you have any questions about the form or the process, please contact:
Brandy Mount 618-241-2144

NOTE!
On-line registration must be completed by noon on the business day proceeding the day of your procedure.


* indicates required information
Today is 11/21/2009
Visit / Procedure Information
* Facility Location: Mt. Vernon Centralia
*Date of Visit:
(mm/dd/yy)
(On-line registration must be completed by noon on the business day proceeding the day of your procedure.)
* Physician Name:
Complaint / Diagnosis:
* Service to Receive:
Surgery Obstetrics
(for Obstetrics only)
Due Date:
(mm/dd/yy)
ACCIDENT INFORMATION
Is your upcoming procedure related to an accident? Yes No
If Yes, you will receive a call to obtain accident information.
ADVANCE DIRECTIVES
Do you have an executed Living Will? Yes No
Do you have an executed Durable Power of Attorney for health care decisions? Yes No

* indicates required information
PATIENT
* Last Name:
* First Name:
Middle Initial/Name:
* Address-1:
Address-2:
* City:
* State:
 * Zip Code:
* Home Phone:
 - -
Email Address:
* Social Security Number:
 - - * Sex: Male Female
* Date of Birth:
 Enter 4-digits for years before 1951.
(mm/dd/yy)
* Race:
 American Indian African American Other
Asian Caucasian Unknown
* Primary Care Physician:
(if no Primary Care Physician, fill in No PCP)
Religion:
* Language:
 English Other:
* Marital Status:
* Have you smoked cigarettes in the last 12 months? Yes No
* Do you have allergies? Yes No

* indicates required information
Legal Guardian / Guarantor
If the patient is over 18, the guarantor is the patient.
Same as Patient (copy from Patient Info; remove check to undo copy)
This is the person responsible for the insurance / bill.
* Last Name:
* First Name:
Middle Initial/Name:
Relation to Patient:
* Address-1:
Address-2:
* City:
* State:
 * Zip Code:
* Home Phone: - -
E-mail Address:
(email address needed to confirm receipt of pre-registration)
* Social Security Number:
 - -
Date of Birth: Enter 4-digits for years before 1951.
(mm/dd/yy)
* Employment Status Full Time Not Employed Self-Employed
Part Time Retired Active Military
Employer:
Work Phone: - - Ext:
Other Phone: - - Ext:

* indicates required information
EMERGENCY CONTACT
* Last Name:
* First Name:
Middle Initial/Name:
* Relation to Patient:
Address-1:
Address-2:
City:
State:
 Zip Code:
* Home Phone: - -
Date of Birth: Enter 4-digits for years before 1951.
(mm/dd/yy)
Social Security Number: - - Sex: Male Female
Employer:
Work Phone: - - Ext:
Other Phone: - - Ext:

* indicates required information
PRIMARY Insurance
* Insurance Plan Name:
Medicare Medicaid
* Policy Number:
Group Number:
If no Group Number, you may leave this blank.
* Name of Policy Holder:
Policy Holder's Date of Birth: (mm/dd/yy)
Patient's Relation to Insurance Holder:
Policy Holder's Employment Status: Full Time Not Employed Self-Employed
Part Time Retired Active Military
Policy Holder's Employer:
(*) Claim Mailing Address-1:
Claim Mailing Address-2:
(*) City:
(*) State:
 (*) Zip Code:
(*) Benefits / Customer Service Phone: - - Ext:
(*) Claim address is not required for Medicare or Medicaid

* indicates required information
SECONDARY Insurance
* Insurance Plan Name:
(or enter the word None )
Medicare Medicaid
* Second Policy Number:
Second Group Number:
If no Group Number, you may leave this blank.
* Name of Policy Holder:
Policy Holder's Date of Birth: (mm/dd/yy)
Patient's Relation to Insurance Holder:
Policy Holder's Employment Status: Full Time Not Employed Self-Employed
Part Time Retired Active Military
Policy Holder's Employer:
(*) Claim Mailing Address-1:
Claim Mailing Address-2:
(*) City:
(*) State:
 (*) Zip Code:
Benefits / Customer Service Phone: - - Ext:
(*) Claim address is not required for Medicare or Medicaid

Other Important Information:


MEDICARE SECONDARY PAYOR (MSP) Information
Patient receiving Black Lung Benefits? Yes No
    Date Black Lung benefits began: (mm/dd/yy)
Are the services to be paid by a government research program? Yes No
Has the DVA authorized
    and agreed to pay for patient's care at this facility? Yes No

Illness / Injury due to work-related accident / condition? Yes No
    Date of injury / illness: (mm/dd/yy)
Work Comp Employer:
Address-1:
Address-2:
City: State: Zip:

Illness / Injury due to NON-work-related accident? Yes No
Type of Accident: Auto Accident Other Accident
Date of Accident: (mm/dd/yyyy)

Patient is entitled to Medicare based on: Age Disability ESRD

Patient Employed? Yes No Never
GHP Coverage?
 Yes No
Spouse Employed? Yes No Never No Spouse
Family Member Employed? Yes No Never No Family Member


(For physician offices)
Pre-Certification Number:
Certified By:





Current Security level:
 
 
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