MCHS On-Line Pre-Registration
   

Registration is necessary for any test,procedure or admission performed at Medical Center Health System. If your doctor did not give you a written order, it may have been faxed to the facility. A written order is required prior to rendering services.

To register, please have the following:

  1. Your Social Security card and/or picture ID
  2. Your insurance card(s)
  3. Doctor's written orders if presented to you by the doctor's office.
  4. Doctor's name.

When all information has been entered, click on the Submit button and your pre-registration will be forwarded to the Registration Department for processing.

To ensure completion of your On-Line Registration, please allow 24 hours for On-Line Registrations to be completed prior to presenting for procedure(s). Please feel free to contact our Pre-Registration Department at (432) 640-1028 to ensure your On-Line Registration has been completed prior to arrival.

Be sure to fill in all spaces that are marked with an asterisk ( * ). These are required fields and your registration cannot be processed without this information.

Patient Information
First Name:   *     Gender:  
Middle Initial:  *     Date of Birth:       *    
Last Name: *   Race:   *    
Address: *   Social Sec. #:        *    
City: *   Marital Status:   *    
State:  *     Cell/Other Phone:      *    
Zip Code:  *     Home Phone #:       *    
               
Employed?   * Employer Name:
        Employer Ph #:        
               
Physician's Name (first and last):  * Date of procedure or service:
Reason for visit:    
   
               
Responsible Party Information
If the patient is a minor, then parent or legal guardian information must be entered here.
Patient Responsible Party? If YES, then skip to the insurance information section. *
     
First Name:     Gender:
Middle Initial:   Date of Birth:    
Last Name:   Race:
Address:   Social Sec. #:    
City:   Marital Status:
State:   Cell/Other Phone:    
Zip Code:   Home Phone #:    
         
Employed?   Employer Name:
      Employer Ph #:    
         
Insurance Information
Primary Insurance Type: Secondary Insurance Type:
Primary Insurance Co. Name: Secondary Insurance Co. Name:
Subscriber's Name: Secondary Insured's Name:
Group #: Group #:
Phone # to verify insurance (Could be located on back of card) :     Phone # to verify secondary insurance (Could be located on back of card)    
Pre-Cert # (could be in back of card )     Secondary Pre-Cert # (could be in back of card    
ID# / Certificate / SS# (as shown on your insurance card): Secondary ID# / Certificate / SS# (as shown on your insurance card):
       
Complete Form
     
Enter your email address to receive notice of when your registration is complete:  
     

When you are ready, click on the Submit Button to send your information to Registration:  
To ensure completion of your On-line Registration, please allow 24 hours for On-line registrations to be completed prior to presenting for procedure(s). Please feel free to contact our Pre-Registration department at (432) 640-1028 to ensure your on-line registration has been completed prior to arrival.
MCHS Pre-Registration Operational Hours are:
Monday - Friday 8am-6pm
Thank you for choosing Medical Center Hospital for your healthcare needs.
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