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Patient Pre-Registration Form

Dear Patient,

Thank you for choosing to Pre-Register with Saint Thomas Rutherford Hospital.  We look forward to serving you on your upcoming visit to our facility.  You can use this secure electronic pre-registration form to submit all of your registration information to us prior to your visit which will speed up your check-in process on the day of your procedure / test.  Once we have received your information, we will pre-register you and verify your insurance benefits for your visit.  One of our associates from our Pre-Services Team will attempt to contact you prior to your visit to go over your specific insurance information if we estimate you will owe any out of pocket expenses. 

If your date of service is less than 48 hours from now, please do not use this on-line pre-registration form but contact us by phone at 615-396-5525.  In addition, should you have any registration or insurance questions prior to service please contact us at the same number above.

Thank you for choosing to Pre-register with Saint Thomas Rutherford Hospital!

* Indicates a required field.

Type of Service

* Please select the type of service you are registering for:
Surgery    Inpatient Visit    Outpatient Procedure/Service Test   OB Delivery/Maternity

Patient Information

Please complete using your legal name.

*Last Name
*First Name
Middle Initial
*Mailing Address
Apt. No.
*City
*State
*Zip Code
 
*Home Telephone
-
Alternate Phone
-
 
Social Security Number
- -
Email Address
 
*Sex
Female      Male
*Birthdate
MM/DD/YYYY
  If patient is under 18 years old, please list parent / guardian
 
*Race (State Requirement)
*Hispanic Origin (State Requirement)
Yes      No
 
*Marital Status
Married      Divorced      Single      Widowed
 
*Primary Language:
Religious Preference
 
*Employment Status
Full-Time
Part-Time
Retired; Retirement Date: MM/YYYY
Unemployed
 
*Employer
*Work Telephone
-


Guarantor/Insured Information
Is patient over 18?

Guarantor or Insured is the person who is responsible for the financial aspects of the visit. If private pay, provide responsible party's information.

*Please indicate who is financially responsible for patient's account:
 
*Last Name
*First Name
*Middle Initial

*Street Address
Apt. No.
*City
*State
*Zip Code
 
*Home Telephone
-
*Social Security Number
- -
 
*Sex
Female      Male
*Birthdate
MM/DD/YYYY
 
*Employment Status   [If Private Pay, check this box: ]
Full-Time
Part-Time
Unemployed
Retired; Retirement Date: MM/YYYY
 
*Employer
*Work Telephone
-


Insurance/Billing Information

*Select one:
Insurance      No Insurance
 
 
Primary Insurance
*Insurance Name
*Name of Insured (as listed on card)
*Member ID/Policy #
*Insured's Relationship to Patient
Group #
Insured's Birthdate
MM/DD/YYYY
Mail Claim To (usually printed on back of insurance card)
Street Address
City
State
Zip Code
Member/Customer Service Phone Number
-
 
Secondary Insurance
Insurance Name
Name of Insured (as listed on card)
Member ID/Policy #
Insured's Relationship to Patient
Group #
Insured's Birthdate
MM/DD/YYYY
Mail Claim To (usually printed on back of insurance card)
Street Address
City
State
Zip Code
Member/Customer Service Phone Number
-


Emergency Contact Information
 
Relationship to Patient
*Last Name
*First Name
Middle Initial
*Home Phone
-
Alternate Phone
-
 


Clinical Information

*This visit is related to (select one):
Pregnancy / OB Related
Surgery
Diagnostic Testing/Procedure
Other
Is this visit related to an accident?
Yes    
No
If accident, please select type:
 
*Date Problem First Started or if Pregnant Date of Last Menstrual Period:
MM/DD/YYYY
*Diagnosis or Chief Complaint
*Primary Care Physician (PCP) or Family Physician
Last Name, First Name
No Primary Care Physician
*Admitting/Attending/Ordering Physician
Last Name, First Name
*Date of Procedure / Expected Due Date
MM/DD/YYYY
Type of Test, Surgery, or Procedure

If any of the above information changes or should you have any questions about your registration or insurance prior to service, please contact the Access Services Department at 615-222-7616.
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