HealthPark Hospital

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• Patient Registration
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Diagnostic Registration Form

I. Patient Information:
Last Name:	A value is required.
First Name:	A value is required.
Physical Address:	A value is required.
City:	A value is required. AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip: A value is required.Invalid format.
Mailing Address: (If different from physical)
City:	AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip:
Home Phone:	A value is required.Invalid format. Work Phone:
Date of Birth:	A value is required.Invalid format. Sex Male Female Required.
Email Address:	A value is required.Invalid format.
Social Security:
Marital Status Single Married Divorced Required.	Race American Indian Asian Black White Other Required. Ethnicity Hispanic Non-Hispanic Please select a valid item. (for reporting purposes only)
Employer:	Occupation:
II. Next of Kin/Closest Living Relative:
Last Name:	A value is required.
First Name:	A value is required.
Address:
City:	AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip:
Relationship to Patient:	A value is required.
Phone:	A value is required.Invalid format.
III. Person to Notify in case of emergency (other than next of kin):
Last Name:	A value is required.
First Name:	A value is required.
Address:
City:	AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip:
Relationship to Patient:	A value is required.
Phone:	A value is required.Invalid format.
IV. Insurance Information:
Insurance Company:	Phone:
Street Address:
City:	AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip:
Name of Policy Holder:
Last Name:
First Name:
Policy Number:
Group Number:
Policy Holder's Employer:	Phone:
Secondary Insurance:	Phone:
Street Address:
City:	AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip:
Name of Policy Holder:
Last Name:
First Name:
Policy Number:
Group Number:
Policy Holder's Employer:	Phone:
V. Responsible Party:
Patient under the age of 18?	Yes No
If "Yes," please continue. If not, go to Section VII.
Parent or Responsible Party's Relationship to Patient:
Last Name:
First Name:
Phone:
Social Security:
Date of Birth:
Address of Responsible Party's (if different than minor)
Address:
City:	AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip:
Employer:	Phone:
VI. Work Information:
Is this work related?	Yes No
If "Yes," please continue. If not, go to Section VIII.
Supervisor or Contact Name:
Last Name:
First Name:
Supervisor Phone:
VII. Reminders/Others:

Please remember to bring the following items with you:

• All insurance, Medicaid, and Medicare Cards
• Photo ID
• Co-insurance and deductibles

Phone Number where we can reach you if we have further questions:
Best time to call you: Morning Afternoon Evening

Comments/Suggestions:

IX. Help With This Form:
If you have questions or need assistance while completing this form, please contact our Patient Coordinator at: 501-520-2000