Pre-Registration

If you choose to complete our Pre-Registration form, please understand that you do so at your own choice. You also assume all responsibility for any liability arising from electronic submission or from any errors or omissions in the data you provide. Any information you choose to give will be used to submit insurance claim forms to Medicare, Medicaid and any other insurance company or payer for which you provide us information.

Pre-Registration Disclaimer

E-mail communication on the Internet may NOT be secure. Catawba Valley Medical Center makes no warranty, express or implied, regarding the security of any information to be submitted to it through this web site. There is a risk that confidential information submitted by you to Catawba Valley Medical Center through this web site, including a completed Pre-Registration Form, may be intercepted illegally by a third party. If you elect to electronically submit a completed Pre-Registration Form, or any other information, to Catawba Valley Medical Center through this web site, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission or from any errors or omissions in the data you provide. You agree to release and hold Catawba Valley Medical Center harmless from any and all liability or cause of action arising from the interception, access or use by a third party of any information submitted electronically by you through this web site or from any errors or omissions in the data you provide. Additionally, the provision of any information to Catawba Valley Medical Center by you through this web site, including a completed Pre-Registration Form, does not create or constitute any relationship between you and Catawba Valley Medical Center (its directors, officers, employees, shareholders, agents or representatives), or any of the physicians who are members of the Medical Staff, to which any privilege may attach.

required fields are marked with an asterisk *

Agree to the Above Terms? *

I Agree
I Do Not Agree

Patient Name, First, Last *

Patient Name, Maiden Name (if applicable)

Patient Email Address *

Expected Admission / Service Date *

Expected Time of Arrival (ex. 7:00am)

Marital Status *

Patient Sex

Male
Female

Patient Birthdate (mm/dd/yy) *

Social Security Number

Religion (Optional)

Patient Home Address *

City *

State *

Country *

Zip Code *

Telephone Number with Area Code *

Admitting Physician (first name, last name) *

Treating Physician (first name, last name) *

Primary / Family Physician (first name, last name) *

Procedure / Treatment / Test *

Nearest Relative or Person to Contact in Case of Emergency *

Relationship *

Address *

City *

State *

Zip Code *

Telephone Number with Area Code *

Patient's Place of Employment

Patient Occupation

Employment Address

City

State

Zip Code

Telephone Number with Area Code

Is Guarantor the same as Patient?

Yes
No

Guarantor / Person Responsible *

Relationship *

Place of Employment / Occupation

Address of Guarantor's Employer

City

State

Zip Code

Business Telephone with Area Code

Guarantor's Social Security Number

Home Address *

City *

State *

Zip Code *

Telephone Number with Area Code *

Primary Insurance Company Name

Insurance Company Telephone Number

Insurance Co. Pre-Certification Telephone Number

Subscriber's Name

Subscriber's Social Security Number

Subscriber's Date of Birth

Policy Group Number

Subscriber's Policy #

Policy Group Name

Address

City / State / Zip Code

Secondary Insurance Company Name

Insurance Company Telephone Number

Insurance Co. Pre-Certification Telephone Number

Subscriber's Name

Subscriber's Social Security Number

Policy Group Number

Policy Group Name

Insurance Co. Address

Insurance Co. City / State / Zip Code

Name of Obstetrician

Due Date

Comments or Questions:

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