Pre Registration

Welcome to the Baptist Hospital's online patient pre-registration form. Use this form to save time by submitting your pre-registration information prior to your admittance. Please do not use this form to submit pre-registration information for a normal doctor's visit.

All fields marked with a red asterisk* are necessary for on-line pre-registration. If you do not have all of the information indicated in red, do not proceed. The system will not accept your registration.

The pre-registration area is currently under construction. Thank you for your patience.

Questions? Call Us: (334) 273-4460

Visit Details

Hospital:*
Patient Type:*
If inpatient, do you want a private room?	Yes No
Visit Date:*
Doctor Ordering Test / Admission : *
Exam : *	(required)
Do you have your doctor's order?	Yes No *if yes, please bring it with you
Reason for test/admission :
Date of onset of symptoms? :
Do you want to be in the hospital directory? :	Yes No

Patient Details

Last Name:*
First Name:*	M.I.
SSN:*
Gender:*	Male Female
Date of Birth:*
Marital Status:
Religion:
Primary Language:
Race:

Work/Day Phone:*
Home/Evening Phone:*
Other Phone:*
Email Address:
Address 1:*
Address 2:
City:*
State:*
Zip:*
Country:*

Employment Status:

Retirement Date:

Employer:
Address:
City:
Zipcode:
Phone:

Guarantor Information

Is the Guarantor the same person as the patient? Yes No

Last Name:*
First Name:*	M.I.
SSN:
Gender:*	Male Female
Relation To Patient:
Date of Birth:*

Work/Day Phone:*
Home/Evening Phone:*
Other Phone:*
Email Address:
Address 1:*
Address 2:
City:*
State:*
Zip:*
Country:*

Employment Status:

Retirement Date:

Relation To Patient:
Employer:
Address:
City:
Zipcode:
Phone:

Emergency Contact

Is the Emergency Contact the same person as the gurantor? Yes No

Last Name:*
First Name:*	M.I.
SSN:
Gender:*	Male Female
Date of Birth:*
Place of Birth:*
Marital Status:

Work/Day Phone:*
Home/Evening Phone:*
Other Phone:*
Email Address:
Address 1:*
Address 2:
City:*
State:*
Zip:*
Country:*

Relation To Patient:
Employer:
Address:
City:
Zipcode:
Phone:

Primary Insurance Policyholder Information

Is this visit due to an accident?

Yes No

If Yes Please Complete Below:
Accident Type:
Place of accident:
Date of Accident:
Time of Accident:
Insurance Company Name:
Insurance Company Address:
Insurance Company Phone:

Is the patient the insurance subscriber?

Yes No

Is the Guarantor the insurance subscriber?

Yes No

Is the Emergency Contact the insurance subscriber?

Yes No

Is this Medicare?

Yes No

Last Name:
First Name:
Middle Name:
SSN#:
Date of Birth:
Relation To Patient:
Insurance:
Address:
City:
Zipcode:
Phone:
Group Name:
Group Number:
Subscriber I.D.:
Authorization Number:
Approved By:

Secondary Insurance Policyholder Information

Is this Medicare?

Yes No

Last Name:
First Name:
Middle Name:
SSN#:
Date of Birth:
Relation To Patient:
Insurance:
Address:
City:
Zipcode:
Phone:
Group Name:
Group Number:
Subscriber I.D.:
Authorization Number:
Approved By:

Medicare

Part I

Are you receiving black lung (BL) Benefits?

Yes No

If Yes Please Complete Below:
Date Benefits Begun:	'
BL IS PRIMARY ONLY FOR CLAIMS RELATED TO BL

Are the services to be paid by a government program such as a research grant?	Yes No
Government Program will pay primary benefits for these services.

Has the Department of Veterans Affairs (DVA) authorized and agreed to pay for care at this facility?	Yes No
DVA IS PRIMARY FOR THESE SERVICES

Was the illness/injury due to a work related accident condition? Yes No

If Yes Please Complete Below:

Date of injury/illness:

Policy of identification number:
WC Plan Company:
Address:
City:
Zipcode:
Employer:
Address:
City:
Zipcode:
Phone:

WC IS PRIMARY PAYER ONLY
FOR CLAIMS RELATED TO WORK RELATED INJURIES OR ILLNESS, GO TO PART II

Part II

Was illness/injury due to a non-work related accident?

Yes No

If Yes Please Complete Below:
Date of Accident:	'

What type of accident caused the illness/injury? AutomobileNon-automobile

Insurance Claim Number:
No-fault or liability insurer:
Address:
City:
Zipcode:

NO-FAULT INSURER IS PRIMARY PAYER ONLY FOR THOSE CLAIMS RELATED TO THE ACCIDENT
GO TO PART III

Was another party responsible for this acccident?

Yes No

If Yes Please Complete Below:

Part III

Are you entitled to Medicare based on:
Age GO TO PART IV
Disability GO TO PART V
ESRD GO TO PART VI

Part IV

Are you currently employed? Yes No

If Yes Please Complete Below:

Employer:
Address:
City:
Zipcode:
Phone:

If No Please Complete Below:

Date of Retirement:

If married, is your spouse currently employed? Yes No

If Yes Please Complete Below:

Employer:
Address:
City:
Zipcode:
Phone:

IF YOU ANSWERED 'NO' TO BOTH QUESTIONS 1 AND 2, MEDICARE IS PRIMARY UNLESS YOU ANSWERED 'YES' TO QUESTIONS IN PART I OR II. DO NOT PROCESS FURTHER.

Are you covered under the group health plan of a family member other than your spouse? Yes No

If Yes Please Complete Below:

Employer:
Address:
City:
Zipcode:
Phone:

Does the employer that sponsors your GHP employ 20 or more employees? Yes No

If No STOP. MEDICARE IS PRIMARY PAYER UNLESS THE PATIENT ANSWERED 'YES' TO QUESTIONS IN PART 1 OR II. Yes. STOP. GHP IS PRIMARY.

If Yes Please Complete Below:

Policy Number:
Group Identification Number:
Name of policyholder/named insured:
Relationship to patient:
Name of GHP:
Address:
City:
Zipcode:

Part V Disability

Are you currently employed? Yes No

If Yes Please Complete Below:

Employer:
Address:
City:
Zipcode:
Phone:

If No Please Complete Below:
Date of Retirement:	'

If married, is your spouse currently employed? Yes No

If Yes Please Complete Below:

Employer:
Address:
City:
Zipcode:
Phone:

IF YOU ANSWERED 'NO' TO BOTH QUESTIONS 1 AND 2, MEDICARE IS PRIMARY UNLESS YOU ANSWERED 'YES' TO QUESTIONS IN PART I OR II. DO NOT PROCESS FURTHER.

Do you have group health plan (GHP) coverage based on your own, or a family member's current employment? Yes No

If No STOP. MEDICARE IS PRIMARY PAYER UNLESS THE PATIENT ANSWERED 'YES' TO QUESTIONS IN PART I OR II.

Are you covered under the group health plan of a family member other than your spouse? Yes No

If Yes Please Complete Below:

Employer:
Address:
City:
Zipcode:
Phone:

Does the employer that sponsors your GHP employ 100 or more employees? Yes No

If No STOP. MEDICARE IS PRIMARY PAYER UNLESS THE PATIENT ANSWERED 'YES' TO QUESTIONS IN PART 1 OR II. Yes. STOP. GHP IS PRIMARY.

If Yes Please Complete Below:

Policy Number:
Group Identification Number:
Name of policyholder/named insured:
Relationship to patient:
Name of GHP:
Address:
City:
Zipcode:

Part VI ESRD

Do you have GHP Coverage? Yes No

If No STOP. MEDICARE IS PRIMARY. Yes. STOP. GHP IS PRIMARY.

If Yes Please Complete Below:

Policy Number:
Group Identification Number:
Name of policyholder/named insured:
Relationship to patient:
Name of Employer
Address:
City:
Zipcode:

Have you received a kidney transplant? Yes No

If Yes Please Complete Below:

Date of Transplant:

Have you received maintenance dialysis treatments? Yes No

If Yes Please Complete Below:

Date dialysis began (If you participated in a self-dialysis training program, provide date training started):

Are you within the 30-month coordination period? Yes No
If No STOP. MEDICARE IS PRIMARY

Are you entitled to Medicare on the basis of either ESRD and age or ESRD and disability? Yes No

Was your initial entitlement to Medicare (including simultaneous or dual entitlement) based on ESRD? Yes No

If Yes STOP. GHP CONTINUES TO PAY PRIMARY DURING THE 30-MONTH COORDINATION PERIOD.

If No STOP. INITIAL ENTITLEMENT BASED ON AGE OR DISABILITY

Does the working aged or disability MSP provision apply (ie. is the GHP primary based on age or disability entitlement)? Yes No

If Yes STOP GHP CONTINUES TO PAY PRIMARY DURING THE 30-MONTH COORDINATION PERIOD.

If No MEDICARE CONTINUES TO PAY PRIMARY.