Patients And Visitors - Patient Registration

Thank you for choosing Memorial Hospital. We want to make your experience here as convenient and efficient as possible. Our Pre-Registration Program allows the hospital to obtain all necessary registration and insurance information prior to your arrival.

You can take advantage of the Pre-Registration program in one of two ways. Please complete the secure on line registration form below or call us directly at 717-815-2351 Monday through Friday from 8 a.m. to 8 p.m. and Saturday from 8 a.m. to 12 p.m.

If you choose to register on-line please do so 48 hours before your expected arrival time. You will also need the following information with you before you begin.

*Your insurance card(s), including Medicare or Medicaid
*Your physician's written order form
*Your Social Security Number
*Your Employment Information
*Emergency Contact Information
*Primary Insurance Holders Date of Birth and Employer Information

Once we receive your Registration form, if additional information is needed you may be contacted by a Pre-Registration Specialist.

This online form is not for emergency visits. Anyone seeking emergency medical attention will be registered in our Emergency Department upon arrival.

General Information

Have you ever been a patient at Memorial Hospital?

Yes
No

Diagnosis/ICD-9 Code(s):

Reason for Visit:

Date:

Appointment Date:

Ordering Physician's Name:

Would you like to receive a copy of our HIPAA Privacy Policy?

Patient Information

Last Name:

First Name:

Middle Initial:

Previous or Maiden Name:

Date of Birth:

Address 1:

Address 2:

City:

State:

Zip:

Telephone 1:

Telephone 2:

Email Address:

Race:

Sex:

Marital Status:

Smoker:

Yes
No

Is the patient under 18 or does the patient have a court appointed guardian or guarantor?

Yes
No

Is the patient currently employed?

Yes
No

Comments:

Employment Information

Employer:

Address 1:

Address 2:

City:

State:

Zip:

Telephone:

Guardian/Guarantor Employment Information

Employer:

Address 1:

Address 2:

City:

State:

Zip:

Telephone:

Primary Insurance

Insured/Subsciber's Name:

Insured/Subscriber's Relationship to Patient:

Insured/Subscriber's Date of Birth:

Member ID/Policy Number:

Group Number:

Insurance Company Name/Carrier:

Insurance Company Address 1:

Insurance Company Address 2:

Insurance Company Member Servers Telephone Number:

Emergency Contact

Full Name:

Relation to Patient or Guardian:

Address 1:

Address 2:

City:

State:

Zip:

Home/Evening Phone Number:

Daytime Phone Number:

Comments: