Baptist Health System 1-877-222-7847
       
 


Thank you for deciding to register online for your procedure(s) at Shelby Baptist.

Please complete this form at least 3 business days prior to your scheduled procedure date.

After you submit this form, you will receive an email or telephone response from our registration personnel prior to your admission.

We respect your privacy and will not use your information for any other purposes than your preregistration with Shelby Baptist .

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Patient Information
First Name:
Middle Name:
Last Name:
Social Security Number: (555-55-5555)
Date of Birth:
Gender:
Race:
Marital Status:
Mother's Maiden Name:
Current Mailing Address:
Address Line 2:
City:
State:
ZIP: (55555-5555)
Home Phone Number: (555-555-5555)
Email Address:
Patient's Chief Complaint:

 

Verification Information
Your relationship to the patient:
Name of the person completing this form 
(if different from patient):
Who should we contact if we have questions about the information provided on this form?
What phone number should we call? (555-555-5555)
What is the best time to contact you?

 

Person Responsible for the Bill
Same as patient?:
First Name:
Middle Name:
Last Name:
Phone Number: (555-555-5555)
Current Mailing Address:
Address Line 2:
City:
State:
ZIP: (55555-5555)
Email address:
Relationship to the patient:
 If Other, please describe:  

 

Nearest Relative
First Name:
Middle Initial:
Last Name:
Nearest relative's relationship to patient:
Street Address:
City:
State:
ZIP: (55555-5555)
Phone Number: (555-555-5555)

 

Procedure #1
Procedure Name:
 (Please list all procedures to be performed.)
Date to Be Performed:
Physician Ordering the Procedure:
First Name:
Last Name:
Family Physician:
First Name:
Last Name:
Procedure Details:
Is this procedure related to an accident?
If yes, date of accident: (MM/DD/YYYY)
If yes, please describe the details of the accident:
Procedure #2
Procedure Name:
 (Please list all procedures to be performed.)
Date to Be Performed:
Physician Ordering the Procedure:
First Name:
Last Name:
Family Physician:
First Name:
Last Name:
Procedure Details:
Is this procedure related to an accident?
If yes, date of accident: (MM/DD/YYYY)
If yes, please describe the details of the accident:
Procedure #3
Procedure Name:
 (Please list all procedures to be performed.)
Date to Be Performed:
Physician Ordering the Procedure:
First Name:
Last Name:

Family Physician:

First Name:
Last Name:

Procedure Details:

Is this procedure related to an accident?
If yes, date of accident: (MM/DD/YYYY)
If yes, please describe the details of the accident:

 

Patient Employment Information
Employment Status:
If retired, please provide 
retirement date: 
Employer: 
Employer Street Address: 
Address Line 2: 
City: 
State: 
ZIP:  (55555-5555)
Phone Number:  (555-555-5555)
Is patient's insurance 
through employer? 

 

Employment Information of 
 Person Responsible for Bill (If Different from Patient)
Employment Status:
If retired, please provide retirement date:
Employer:
Employer Street Address:
Address Line 2:
City:
State:
ZIP: (55555-5555)
Phone Number: (555-555-5555)
Is patient's insurance through this employer?

 

Insurance
Are you insured?
Insurance #1
Does this insurance company know the patient is having this procedure?
Primary Insurance Name:
Insured Name:
Insured's Date of Birth:
ID/Policy Number:
Is this a group policy?
Group Name:
Group Number:
Telephone number we should call to verify benefits: (555-555-5555)
Precertification phone number: (555-555-5555)
Billing Address:
Address Line 2:
City:
State:
ZIP: (55555-5555)
Insurance #2
Does this insurance company know the patient is having this procedure?
Primary Insurance Name:
Insured Name:
Insured's Date of Birth:
ID/Policy Number:
Is this a group policy?
Group Name:
Group Number:
Telephone number we should call to verify benefits: (555-555-5555)
Precertification phone number: (555-555-5555)
Billing Address:
Address Line 2:
City:
State:
ZIP: (55555-5555)

 

Additional Information

Please enter any additional information you believe would be helpful in completing your preregistration:




 

 


3201 4th Avenue South  |  Birmingham, AL 35222  |  1-877-222-7847