Patient Pre-Registration Form 
* Indicates a required field

* Date of Service: (mm/dd/yyyy) * Time: (hh:mm)
If Pregnant,
Due Date:
(mm/dd/yyyy)
* Ordering Physician: Appointment Type:

 


Patient Information

* Last Name: * First name:
* Middle: Prior Legal Name:
* Gender:
* Street Address:
* City:
* State:
* Zip:
* Home Phone: (xxx-xx-xxxx)
* Birth Date: (mm/dd/yyyy)
Age:
* Social Security Num: (xxx-xx-xxxx)

 

Marital Status:
Single
Married
Widowed
Divorced
Separated






Race:
White
Black
American Indian
Asian
Bi-Racial
Hispanic
Other







 

Have you ever been treated
at Good Samaritan Hospital?:
Yes No

 

* Religious Preference:
* Employer Name: * Patient Occupation:
* Employer Address:
* Employer Phone: (xxx-xxx-xxxx)
* Employment Status:
Full Time Part Time Self Employed Retired
Student Unemployed Not Employed Military Active Duty

 


Nearest Relative/Emergency Contact

Name of Relative:
(if married, list spouse)
Relationship to Patient:

 

Same as Patient:
Street Address:
City:
State:
Zip:
Home Phone: (xxx-xxx-xxxx)
Other Phone: (xxx-xxx-xxxx)

 


Patient Insurance Information

Insurance: Yes No

Medicare Information Primary Secondary

 

Coverage Based On: Age Disability ESRD
Medicare Number as Printed on Card:
Part A Coverage: Yes No
Part B Coverage: Yes No
Patient Retirement Date: Spouse's Retirement Date:

 


Insurance Information 1 Primary Secondary

 

Insurance Company Name:
Billing Address:
City:
State:
Zip:
Phone Number:
Insured's Name:
(if married, list spouse)
Insured's Date of Birth:
Insured's Relationship to Patient: Insured's Social Security #:
Policy/ID Number: Claim Number:
(if applicable)
Group Name: (Employer) Group Number:
Insured Employment Status:
Full Time Part Time Self Employed Retired
Student Unemployed Not Employed Military Active Duty

 


Insurance Information 2 Primary Secondary

 

Insurance Company Name:
Billing Address:
City:
State:
Zip:
Phone Number:
Insured's Name:
(if married, list spouse)
Insured's Date of Birth:
Insured's Relationship to Patient: Insured's Social Security #:
Policy/ID Number: Claim Number:
(if applicable)
Group Name: (Employer) Group Number:
Insured Employment Status:
Full Time Part Time Self Employed Retired
Student Unemployed Not Employed Military Active Duty

 


Medicaid Information Nebraska Other (Please specify other)

 

Name as it Appears on Card:
Medicaid Number as it Appears on Card: Effective Date: (mm/dd/yyyy)
Managed Care: Yes No
Name of Managed Care Plan: PCP: