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Patient Registration Information

For your convenience, we have provided an online patient registration form.  You can also print a blank form, fill it out and mail it to our office using the address on the form.  Patient Registration Form
Please be prepared to provide a copy of your health insurance card. You may also need to provide insurance forms supplied by your employer or insurance company. All patients should familiarize themselves with the terms of their insurance coverage.

It is important for you to know what services your insurance does and does not cover, as any uninsured portion is the patient's responsibility. If you do not know your insurance requirements, we ask that you check on your insurance coverage before returning this form.

This page uses encryption protocols to ensure the security of your information.


Pre-Registration Information

Procedure You're Receiving:

Patient Information

(If not employed, put ”NONE“)

Emergency Contact Information

Financial Responsibility

 Check to copy patient information to financial section
If insured, name of person who holds insurance
(If not employed, put ”NONE“)

Medicare Information

Are you covered by Medicare:

Medicaid Information

Are you covered by Medicaid:

Patient Insurance Information

Do you have insurance?:
(Claims address listed on card)
(Whose name is the insurance in?)
Do you have a secondary insurance company?:

Baby's Insurance Information

Will baby be covered under insurance?:
Select below to copy baby's insurance information from either primary or secondary insurance information:


Upon receipt of this completed pre-registration form, a representative will verify your insurance and then follow up with you regarding any deductible and/or co-payment that may be due at the time of service.

Please bring all insurance cards and driver's license with you to patient registration when you arrive.
If you have any questions regarding insurance or payment options, please contact our financial counselor at 812-842-4240.

Email communications are not a secured form of communications.

If Email notification has been selected, only your confirmation information and requests for insurance information will be sent in the email message. No other patient information will be sent.

If additional information is needed, you will be contacted by phone.

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