Get Hospital Pre-admission Form

Completing the Hospital Pre-admission Form online is a crucial step in preparing for your hospital visit. This guide will provide you with clear instructions to ensure that you fill out the form accurately and efficiently.

Follow the steps to complete your pre-admission form online.

1. Click ‘Get Form’ button to access the Hospital Pre-admission Form and open it in the online editor.
2. Begin by entering your patient information. Fill in your full name, including maiden name, and Social Security number. Provide your birth date and home phone number. Ensure your mailing address is complete, including city, state, and zip code. Indicate your marital status by circling the appropriate option.
3. In the race section, circle your race from the options provided. Fill in your religion and church preference if applicable.
4. Provide your employment information, including your employer's name, occupation, and work phone number. Fill out your employer's address and city, state, and zip code.
5. Indicate your expected date of admission and select the type of services you anticipate receiving by circling the correct option.
6. Document the date of your last menstrual period and provide the name of your primary care physician.
7. Enter your diagnosis and the admitting physician’s name. Also, indicate if you have previously received services at Hillcrest Health System by circling 'yes' or 'no'.
8. If applicable, note whether your insurance company has been notified of your admission and make any necessary payments at the time of registration.
9. Fill out the insurance information for your primary insurance. Provide the insurance company's name, address, contact number, policy number, group number, and effective date.
10. If you have secondary insurance, complete the same information for your secondary insurance provider.
11. Provide spouse or guarantor information, including their name, Social Security number, birth date, and contact details.
12. Enter a contact person to notify in case of an emergency, including their name and relationship to you.
13. Document next of kin information, ensuring they are not the same person as your emergency contact.
14. Indicate if you have a living will and whether it is filed at Hillcrest. If you can bring a copy at the time of registration, note that as well.
15. Once you have completed all sections of the form, review your entries for accuracy. You may save changes, download, print, or share the form as required.

Start completing your Hospital Pre-admission Form online today for a smooth registration experience.