Hospital Patient Registration Form

Prior to your scheduled service or admission, we suggest you complete our pre-registration form. Below is our secure and HIPAA compliant form. Completing this in advance minimizes your check in time and allows us to assist you with financial arrangements as needed. Please submit the completed form at least 3 business days prior to your scheduled services. If you choose to fill out the form less than 3 days before your date of service, you may be asked similar questions upon arriving for your appointment. Keep in mind, if you fill out the form during non-business hours, your information will not be reflected until the next business day.

If you prefer to pre-register over the phone, please contact us at 608-643-7528. You will be prompted to leave a voicemail and we will contact at our earliest convenience. Our office hours are Monday-Friday 9:00 am - 5:30 pm.

Upon check in, please provide your insurance cards, a valid ID and advance directive (if applicable) to the receptionist.

Reason for Visit*

Inpatient SurgeryOutpatient VisitBirth

Patient Name*

First NameMiddle InitialLast Name

Date of Birth*

MonthDayYear

Age

Sex*

SSN (use format xxx-xx-xxxx)

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What County?*

Have you traveled outside the US in the last 30 days? *

Y/N

If YES, what country and are you feeling ill?

Phone Number*

Area Codexxx-xxxx

Phone Number - Secondary

Area Codexxx-xxxx

Receive E-mails?*

Y/N

E-mail (required if you want to access your health record securely online?

Marital Status*

Sauk Prairie Healthcare does not discriminate against patients due to race or ethnicity. The Federal Government has provided new guidelines for collecting the following information.

Race*

Ethnicity*

Preferred Language*

Do you have Advance Directives (Living WIll)? (Y/N)

Employment

Current Employment Status*

Employer Name*

NA if Unemployed, Disabled or Retired

Employer Phone

Area CodePhone Number

Employer Address

In case of emergency...

Primary Emergency Contact*

First NameLast Name

Address:

Contact Number*

Area CodePhone Number

Relationship*

Secondary Emergency Contact:

First NameLast Name

Address

Contact Number

Area CodePhone Number

Relationship

If Patient is a Minor complete the following:

Guarantor Name

First NameLast Name

Guarantor Address

Guarantor Phone

Area CodePhone Number

Relationship to Minor

Guarantor Employment Status

Guarantor Employer Name

Guarantor Employer Address

Guarantor Employer Phone

Area CodePhone Number

Primary Insurance Information

Do you have insurance?*

YesNo

Is the patient the primary insurance subscriber?*

YesNo

Primary Insurance Name*

Policy Number*

Group Number

Insurance Phone Number

Secondary Insurance Information

Do you have secondary Insurance?*

YesNo

Secondary Insurance Name

Policy Number

Group Number

Insurance Phone Number

If the patient is not the subscriber, please provide insurance subscriber's information:

Name

Birthdate

SSN (use format xxx-xx-xxxx)

Relationship to Patient

Provider

Primary Care Provider*

Provider Location

Complete This Portion for Maternity Admission

Expected Delivery Date (use format MM/DD/YYYY)

Admitting Doctor

Baby Last Name

Baby Doctor

Additional Notes

Pre-Registration