Get Pre-registration Form - Rex Healthcare

Completing the Pre-Registration Form for Rex Healthcare is an essential step for new patients to ensure a smooth visit. This guide will provide you with clear and supportive instructions on how to fill out the form online, aiding you in gathering necessary information effectively.

Follow the steps to complete the pre-registration form easily.

1. Click the ‘Get Form’ button to obtain the Pre-Registration Form and open it in your preferred editing tool.
2. Begin by ensuring all required fields are completed. This includes personal information such as the patient's legal name, contact details, and insurance information.
3. In the 'Type of Service' section, select the applicable procedure that you will be receiving. This could range from cardiovascular procedures to surgery.
4. Fill out the 'Patient Information' section thoroughly, providing details like social security number, date of birth, race, and marital status.
5. In the 'Employment Information' section, include the patient's employment status, if applicable, along with employer details.
6. Complete the 'Guarantor Information' section, noting the individual financially responsible for the patient, including their relationship to the patient and contact details.
7. Provide details for the 'Emergency Contact' section, which should include the name, relationship to the patient, and contact information.
8. Include any relevant medical information, such as admitting physicians and whether the patient is enrolled in a hospice program.
9. If applicable, complete the 'Accident Information' section, detailing the nature of the accident and relevant specifics.
10. Fill in the 'Primary Insurance' and 'Secondary Insurance' sections, providing all necessary details about insurance plans, policyholders, and policy numbers.
11. Once all sections are completed, ensure your signature is affixed, along with the date signed to the bottom of the form.
12. Finally, save your changes to the form. You can then download, print, or share it as needed, and fax or mail it to the designated address.

Complete your Pre-Registration Form online today for a seamless visit to Rex Healthcare.