Patient Pre-Registration - Cullman Regional Medical Center

Patient Information

Patient Full Name*

Address*

Mailing Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Secondary Address

Mailing Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

Secondary Phone

Patient Email

Social Security Number*

Date of Birth

Marital Status

Race

Primary Language

Sex/Gender

Male
Female

Does the patient smoke?

Yes
No

Would you like your visit to Cullman Regional to be confidential?

Yes
No

Do you have an advance directive?

Yes
No

An advance directive is used to tell your doctor and family what kind of medical care you want if you are unable to speak or make decisions for yourself. If you do not have an advance directive and are unable to make decisions about your health care, members of your family will have to decide on your care for you.

Emergency Contact

Contact's Full Name*

Relationship to Patient*

Contact's Primary Phone*

Contact's Secondary Phone

Employment Information

Employment Status*

Employed
Unemployed
Retired
Disabled

Employer's Name*

Employer's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Position/Title*

Type of Position*

Full Time
Part Time
PRN
N/A

Retirement Date

Responsible Party Information

Is the patient listed above the responsible party?*

Yes
No

Please fill out the responsible party information:

Full Name*

Relationship to Patient*

Date of Birth

Social Security Number*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

Secondary Phone

Email

Employer

Employer's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer's Phone Number*

Position/Title

Type of Position*

Full Time
Part Time
PRN
N/A

Payment Information

Is this visit/procedure related to a Worker's Compensation claim?*

Yes
No

Is this visit/procedure related to an Auto Liability claim?*

Yes
No

How do you plan to pay?

Insurance
Cash
Medicare
Medicaid

Insurance Information

Insurance Provider*

Policy Holder/Beneficiary*

Policy/Contract Number or Member ID*

Group Number*

Policy Effective Date

Secondary Insurance Provider

Secondary Insurance Policy Holder/Beneficiary

Secondary Insurance Policy/Contract Number or Member ID

Secondary Insurance Group Number

Secondary Insurance Effective Date

Information About the Upcoming Visit to Cullman Regional

Procedure/Test Date*

What type of procedure are you having?*

Primary Physician*

Referring Physician