Pre-Registration

1. Patient Information:
2. Last Name(required)
3. First Name(required)
4. Date of Birth(required)
5. Email(valid email required)
6. Gender Female Male (required)
7. Social Security Number
8. Marital Status Divorce Married Single (required)
9. Address(required)
10. City(required)
11. State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming (required)
12. Zip(required)
13. County(required)
14. Preferred Method of Contact Cell Phone Email Work Phone (required)
15. Work Phone
16. Cell Phone
17. Appointment Information:
18. The test or procedure you are having or the Department where you will be having a test or procedure done(required)
19. Appointment Date (if known)
20. Appointment Time (if known)
21. Diagnosis / Symptoms
22. Other Conditions such as Diabetes, congestive heart failure, etc
23. Physician first and last name(required)
24. Is this visit due to an accident? Yes No
25. Work related accident? Yes No
26. Description of accident
27. Next of Kin Information:
28. Other than responsible party
29. Name
30. Relationship
31. Address
32. Phone
33. Employment Information:
34. Status Not Employed Retired Full Time Part Time Self Employed
35. If retired, date of retirement
36. Employer Name
37. Employer Address
38. Employer Phone Number
39. Patient Responsibility:
40. If you are the patient this information does not need to be completed. This information is for the person responsible for payments.
41. Last Name
42. First Name
43. Address
44. Phone Number
45. Work Phone Number
46. Cell Phone Number
47. Your relationship to patient Brother Father Grandfather Grandmother Husband Mother Sister Wife
48. Social Security Number
49. Date of Birth
50. Employer
51. Employer Address
52. Employer Phone Number
53. Employment Status Not Employed Retired Full Time Part Time Self Employed
54. Primary Insurance:
55. Insurance Company Name (If Medicare, list Medicare. For Medicare covered patients, the other fields in Primary Insurance are not needed.)
56. Billing Address
57. City
58. State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
59. Zip Code
60. Policy Holder Name
61. Relationship to Patient
62. Policy Holder Date of Birth
63. Policy Holder Social Security Number
64. Group Number
65. Policy Holder Certificate or ID Number
66. Secondary Insurance:
67. Insurance Company Name
68. Billing Address
69. City
70. State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
71. Zip Code
72. Policy Holder Name
73. Relationship to Patient
74. Policy Holder Date of Birth
75. Policy Holder Social Security Number
76. Group Number
77. Policy Holder Certificate or ID number
78. Do we have your permission to list your name in our public hospital directory? Is it ok for us to let people know you are here when they contact the hospital looking for you? Yes No (required)
79. Consent Agreement:
80. I allow the release of information for claims and reimbursement purposes and I assign benefits to SEORMC.
81. I acknowledge that I have received or have been provided access to the Southeastern Med Privacy Policy, Privacy practices for Protected Health Information and the SEORMC.org Disclaimer and have been given an opportunity to read it and ask questions. I understand the Southeastern Med Privacy Practices outline the way in which my medical information may be used or disclosed.
82. I agree to these terms. (Initials)(required)
83. You must agree before submitting your pre-registration information.
84. What color is snow?

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