Online Pre-Registration Form



Thank you for submitting your registration information prior to your visit.


Upon your arrival at the hospital, please stop at the Patient Registration area to complete the registration process.

NOTE:  Here are some tips to keep in mind when filling out the form:

  • You may need to refer to your insurance card(s) to answer some of the questions. If you have insurance, please have your insurance card(s) available.
  • The patient registration staff will contact you if your information needs clarification or is incomplete.
  • * indicates a required field. It cannot be blank.

This page uses encryption protocols to ensure the security of your information.
Pre-Registration Information
(MM/DD/YYYY)
What procedure are you going to receive?: *
*
*
Patient Information
*
*
*
 -  -
Sex: *
* (MM/DD/YYYY)
*
*
*
*
*
*
( - 
( - 
*
*
CalendarNow
* (if no employed, put “None”)
( - 
Emergency Contact Information
*(Emergency Contact)
*
*
( - 
(Secondary Emergency Contact)
( - 
Financial Reposibility
 Check to copy patient information to financial section
* If insured, name of person who holds insurance
*
*
*
*
( - 
*
 -  -
* (MM/DD/YYYY)
* (If not employed, put ”NONE“)
* (If not employed, put ”NONE“)
( - 
( - 
Medicare Information
Are you covered by Medicare: *
Medicaid Information
Are you covered by Medicaid: *
Are you receiving Social Security checks:
Patient Insurance Information
Do you have insurance?: *
(Claims address listed on card)
( - 
(Whose name is the insurance in?)
 -  -
Individual or Group Policy:
Do you have a secondary insurance company?:
(Claims address listed on card)
( - 
(Whose name is the insurance in?)
 -  -
Individual or Group Policy?:
Baby's Insurance Information
Will baby be covered under insurance: *
(If yes, have you notified the insurance company?)
(Customer Service Number)
( - 
(Whose name is the insurance in?)
 -  -
Individual or Group?:
Follow-up
Upon receipt of this completed pre-registration form, a representative will verify your insurance and then follow up with you regarding any co-insurance payment that may be due at the time of service.
Follow-up Contact Method:
(Email is NOT a secure form of communication More information)
( - 
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.