Forms

Forms

HealthEast Pre-Registration Form

Before your visit, please complete a pre-registration form. You can either fill out the form below or call HealthEast Pre-Registration at 651-232-5855.

We also suggest that you consult your insurance company to determine your benefits and any pre-authorization or referral requirements.

Please note: This form may not work with some versions of Internet Explorer. If you are having trouble submitting the form, please try a different browser.

*Required fields

Patient information

Location of service*
Please select a location.

Legal first name*
Enter your first name.

Middle initial*
Enter your middle initial, or N/A
if you do not have one.

Enter N/A if you do not have one.

Last name*
Enter your last name.

Maiden name
Invalid Input

E-mail address
Invalid Input

Subject
Invalid Input

Sex*
Designate your sex.

Birth date*
Enter your date of birth.

xx/xx/xxxx

Marital status*

Indicate your marital status.

Last four digits of SSN
Enter the last four digits
of your Social Security number.

Address*
Enter your street address.

Apartment number
Invalid Input

City*
Enter your city.

State*
Select your state.

Zip code*
Enter your zip code.

Best phone number*
Enter the best number at which to reach you.

xxx-xxx-xxxx

Type of phone*
Indicate the type of phone.

Alternate phone number
Enter an alternate phone number.

xxx-xxx-xxxx

Type of phone
Invalid Input

Alternate phone number
Enter a valid phone number.

xxx-xxx-xxxx

Type of phone
Invalid Input

Do you have a health care directive (living will)?

Invalid Input

Do you participate in any clinical trials/research studies?

Invalid Input

Which studies? *
List the studies.

Do you need an interpreter?

Invalid Input

Language preference *
Specify a language.

Is the patient currently employed? *

Indicate employment status.

Retirement date
Invalid Input

Employer's phone
Invalid Input

Occupation
Invalid Input

Employer
Invalid Input

Employer's address
Invalid Input

Primary doctor's first name
Enter your primary doctor's first name.

Primary doctor's last name*
Enter your primary doctor's last name.

Primary doctor's clinic & location*
Enter your doctor's clinic and its location.

Enter "No primary" if you do not have a primary care clinic.

Guarantor information

If you are under the age of 18 and not an emancipated adult, you cannot list yourself as guarantor. However if you are under the age of 18 and pregnant you can list yourself as guarantor.
Guarantor (person responsible for the bill)*

Select the guarantor.

Guarantor name *
Enter the name of the person
responsible for the hospital bill.

Birth date *
Enter the birth date.

Address *
Enter the guarantor's address.

Apt. #
Invalid Input

City *
Enter the guarantor's city.

State *
Select the guarantor's state.

Zip code *
Enter the guarantor's zip code.

Phone number *
Enter the guarantor's phone number.

xxx-xxx-xxxx

Is the guarantor currently employed? *

Indicate employment status.

Retirement date
Invalid Input

Employer's phone
Invalid Input

Occupation
Invalid Input

Employer
Invalid Input

Employer's address
Invalid Input

Patient's relationship to guarantor *

Enter the patient's relationship to guarantor.

Last four digits of SSN
Enter the last four digits
of the guarantor's Social Security number.

Visit information

Reason for visit*
Enter the reason for the visit.

Is this visit due to an injury?*

Indicate if this visit is due to an injury.

What was the cause of your injury? *
Enter the cause of injury.

What type of insurance will you be using for this visit?*

You must choose an option.

Income level

Income *
Indicate your income level.

Reason for visit

Please indicate the type of claim *

Indicate if this is a worker's compensation
or motor vehicle accident.

Date and time of injury *
Enter the date of your injury.

Place of accident
Invalid Input

Part of body injured *
Indicate what part of the body was injured.

Insurance company for accident claim *
Enter the insurance company
name for your claim.

Insurance phone *
Enter the insurance company's phone number.

xxx-xxx-xxxx

Insurance address
Invalid Input

Enter your claim number
Invalid Input

Claims adjustor name
Invalid Input

Primary insurance policy

Health insurance name *
Enter insurance name.

Policy holder first name*
Enter the first name of the policy holder.

Policy holder last name *
Enter the last name of the policy holder.

Policy holder birth date *
Enter the insured's date of birth.

Relationship to patient *
Enter the relationship to patient.

Policy/ID number *
Enter the policy number.

Employer/group name *
Enter your group name.

Group number *
Enter your group number.

Member services phone *
Provide the member
services phone number.

Claims address *
Enter the insurance address.

Additional insurance

Invalid Input

Second insurance policy

Health insurance name *
Enter insurance name.

Policy holder first name*
Enter the name of the policy holder.

Policy holder last name *
Enter the last name of the policy holder.

Policy holder birth date *
Enter the insured's date of birth.

Relationship to patient *
Enter the relationship to patient.

Policy/ID number *
Enter the policy number.

Employer/group name *
Enter your group name.

Group number *
Enter your group number.

Member services phone *
Provide the member services phone number.

Claims address *
Enter the insurance address.

Third insurance policy

Health insurance name *
Enter insurance name.

Policy holder first name *
Enter the first name of the policy holder.

Policy holder last name *
Enter the last name of the policy holder.

Policy holder birth date *
Enter the insured's date of birth.

Relationship to patient *
Enter the relationship to patient.

Policy/ID number *
Enter the policy number.

Employer/group name *
Enter your group name.

Group number *
Enter your group number.

Member services phone *
Provide the member services phone number.

Claims address *
Enter the insurance address.

Patient representative and alternate contact

If at any time you are unable to speak for yourself during or following your procedure, who would you like to list as a contact to involve in your care planning?
Name (first last)*
Enter your Emergency Contact

Relationship*
Enter the relationship of your emergency contact.

Main phone*
Enter the emergency contact's phone number.

Alternative phone
Invalid Input

Alternate contact*
Select "same as above" or "other"

Alternate contact's name *
Enter spouse or nearest
relative's first name.

Relationship *
Enter this person's relationship to you.

Main phone number *
Enter the relative's phone number.

xxx-xxx-xxxx

Alternative phone number
Invalid Input


Additional information

We review all patients' treatment to ensure that everyone receives the highest quality of care. To help with our review, can you please provide your race, country of origin and religion.


What race best describes you?
Invalid Input

In what country were you born?
Invalid Input

What religion do you practice?
Invalid Input

Would you like us to notify a church of your inpatient stay?*
Indicate if you want a church notified.


Church name and phone number *
Enter the church name and phone number.


After clicking the "Submit" button below, you will be taken to a confirmation page.

If you do not see a confirmation page when you submit the form, it means there are form fields that were not filled out. Please scroll up and look for red text that indicates missing information.

Once this is corrected, the form will submit properly.