CLARK REGIONAL MEDICAL CENTER - Online Pre-Registration Form

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Please register online any time of the day or night, as long as your scheduled visit is at least 3 business days from the date you complete the pre-registration information.

This service is available for scheduled visits only. We hope this will make registering more efficient and decrease your wait time. On the date of your procedure or test, please visit registration upon arrival to verify all information, provide your insurance cards and to sign appropriate documents.

Thank you for choosing Clark Regional Medical Center to provide for your health care needs.

If you have questions about surgery registration call (859) 745-3433 or diagnostic testing call (859) 745-3578. You can call between 8:00 a.m. and 5:00 p.m.

All * fields are required. Please take the time to fill in these fields. If a question does not apply to you, please fill in N/A.

*Doctor's Name:
*Expected Date of Service:
*Admit Time:
*What type of patient are you:	Inpatient Outpatient Maternity Outpatient Surgery
Religion/Church Name:
*Complaint/Diagnosis:

Patient Information
*Last Name:
*First Name:
*Middle Initial:
Maiden Name:
*Date of Birth: (00/00/0000)
*Street Address:
*City:
*State:
*Zip code:
*County:
*Drivers Lic#
*Phone Number (with area code):
*Social Security #:
*Sex:	Male Female
*Are you:	Single Widowed Divorced Married Separated
Race (Optional):	Caucasian Asian African/American Hispanic Other
*Employer's Name:
Address:
City:
State:
Zip Code:
*Phone Number (with area code):
What schedule did you work?	Full Time Part Time Temporary
*Advance Directive:	Yes (Bring with you on date of service) No
*Spouse's name or parent/guardian name if minor:
*Employer's Name:
Address:
City:
State:
Zip code:
Phone Number (with area code):

Guarantor Information - Person Responsible for Payment
*Last Name:
*First Name:
Middle Initial:
*Street Address:
*City:
*State:
*Zip code:
*Phone Number (with area code):
*Social Security #:
*Employer's name:
Address:
City:
State:
Zip Code:
Phone Number (with area code):
*What did you work:	Full Time Part Time Temporary
*Relationship to patient:

Emergency Contact (other than home phone)
*Name:
*Address:
*City:
*State:
*Zip Code:
*Phone Number (with area code):
*Relationship to Patient:

One of the following must be answered:
Date symptoms began:
Last menstrual cycle (maternity):
If service required is due to an accident, what was the date of the accident:
What was the time of the accident:
Please describe the accident:

Pre-Certification Information: If your insurance requires pre-certification; this is the responsibilty of you and your physician.
Pre-Certification or Authorization #:

Insurance Information
Do you have insurance? If yes*, please list all medical insurance below. At least one section below must be filled in.
Yes No

Blue Cross Information
Name if subscriber as listed on card:
ID#:
Group #:
Plan Code #:
Date of birth of subscriber: (00/00/0000)

Commercial Insurance Information
Name of Insurance:
Name of Subscriber as listed on card:
ID#
Group#:
Group Name:
Date of birth of Subscriber: (00/00/0000)

Medicare
Name as listed on card:
ID#:
Hospital Benefits? (Part A)	Yes No
Medical Benefits? (Part B)	Yes No

Medicaid
Name as listed on card:
ID#:

Secondary Information
Name of insurance:
Name of Subscriber as listed on card:
ID#:
Group#:
Date of birth of Subscriber: (00/00/0000)

Payment Information: All Co-pays, coinsurance, and/or Deductibles are due at time of service. Your benefits will be verified and you will be contacted and informed of your financial responsibility prior to the date of service. If we are unable to contact you prior to that date, you will be informed of your responsibility when you arrive at time of registration. We accept cash, check, debit cards, Visa, Mastercard, American Express and Discover. If financial arrangements are necessary, you may speak with a financial counselor at (859) 745-3486 or (859) 745-3433. Thank you.