AddThis Social Bookmark Button
Home Pre-register Other Pre-registration (includes outpatient cardiovascular)
Pre-Register for Your Visit

 

HealthEast Pre-Registration Form

  1. 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.

    *Required fields

  2. Patient information

  3. Location of service*
    Please select a location.
  4. Legal first name*
    Enter your first name.
  5. Middle initial*
    Enter your middle initial, or N/A
    if you do not have one.
    Enter N/A if you do not have one.
  6. Last name*
    Enter your last name.
  7. Maiden name
    Invalid Input
  8. E-mail address
    Invalid Input
  9. Subject
    Invalid Input
  10. Sex*
    Designate your sex.
  11. Birth date*
    Enter your date of birth.
    xx/xx/xxxx
  12. Marital status*






    Indicate your marital status.
  13. Last four digits of SSN
    Enter the last four digits
    of your Social Security number.
  14. Address*
    Enter your street address.
  15. Apartment number
    Invalid Input
  16. City*
    Enter your city.
  17. State*
    Select your state.
  18. Zip code*
    Enter your zip code.
  19. Best phone number*
    Enter the best number at which to reach you.
    xxx-xxx-xxxx
  20. Type of phone*
    Indicate the type of phone.
  21. Alternate phone number
    Enter an alternate phone number.
    xxx-xxx-xxxx
  22. Type of phone
    Invalid Input
  23. Alternate phone number
    Enter a valid phone number.
    xxx-xxx-xxxx
  24. Type of phone
    Invalid Input
  25. Do you have a health care directive (living will)?


    Invalid Input
  26. Do you participate in any clinical trials/research studies?


    Invalid Input
  27. Which studies? *
    List the studies.
  28. Do you need an interpreter?


    Invalid Input
  29. Language preference *
    Specify a language.
  30. Is the patient currently employed? *



    Indicate employment status.
  31. Retirement date
    Invalid Input
  32. Employer's phone
    Invalid Input
  33. Occupation
    Invalid Input
  34. Employer
    Invalid Input
  35. Employer's address
    Invalid Input
  36. Primary doctor's first name
    Enter your primary doctor's first name.
  37. Primary doctor's last name*
    Enter your primary doctor's last name.
  38. 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.

  40. Guarantor information

  41. 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.
  42. Guarantor (person responsible for the bill)*


    Select the guarantor.
  43. Guarantor name *
    Enter the name of the person
    responsible for the hospital bill.
  44. Birth date *
    Enter the birth date.
  45. Address *
    Enter the guarantor's address.
  46. Apt. #
    Invalid Input
  47. City *
    Enter the guarantor's city.
  48. State *
    Select the guarantor's state.
  49. Zip code *
    Enter the guarantor's zip code.
  50. Phone number *
    Enter the guarantor's phone number.
    xxx-xxx-xxxx
  51. Is the guarantor currently employed? *



    Indicate employment status.
  52. Retirement date
    Invalid Input
  53. Employer's phone
    Invalid Input
  54. Occupation
    Invalid Input
  55. Employer
    Invalid Input
  56. Employer's address
    Invalid Input
  57. Patient's relationship to guarantor *



    Enter the patient's relationship to guarantor.
  59. Last four digits of SSN
    Enter the last four digits
    of the guarantor's Social Security number.

  61. Visit information

  62. Reason for visit*
    Enter the reason for the visit.
  63. Is this visit due to an injury?*


    Indicate if this visit is due to an injury.
  64. What was the cause of your injury? *
    Enter the cause of injury.
  66. What type of insurance will you be using for this visit?*





    You must choose an option.

  67. Income level

  68. Income *
    Indicate your income level.

  69. Reason for visit

  70. Please indicate the type of claim *


    Indicate if this is a worker's compensation
    or motor vehicle accident.
  71. Date and time of injury *
    Enter the date of your injury.
  72. Place of accident
    Invalid Input
  73. Part of body injured *
    Indicate what part of the body was injured.
  74. Insurance company for accident claim *
    Enter the insurance company
    name for your claim.
  75. Insurance phone *
    Enter the insurance company's phone number.
    xxx-xxx-xxxx
  76. Insurance address
    Invalid Input
  77. Enter your claim number
    Invalid Input
  78. Claims adjustor name
    Invalid Input

  79. Primary insurance policy

  80. Health insurance name *
    Enter insurance name.
  81. Policy holder first name*
    Enter the first name of the policy holder.
  82. Policy holder last name *
    Enter the last name of the policy holder.
  83. Policy holder birth date *
    Enter the insured's date of birth.
  84. Relationship to patient *
    Enter the relationship to patient.
  85. Policy/ID number *
    Enter the policy number.
  86. Employer/group name *
    Enter your group name.
  87. Group number *
    Enter your group number.
  88. Member services phone *
    Provide the member
    services phone number.
  89. Claims address *
    Enter the insurance address.
  90. Additional insurance


    Invalid Input

  91. Second insurance policy

  92. Health insurance name *
    Enter insurance name.
  93. Policy holder first name*
    Enter the name of the policy holder.
  94. Policy holder last name *
    Enter the last name of the policy holder.
  95. Policy holder birth date *
    Enter the insured's date of birth.
  96. Relationship to patient *
    Enter the relationship to patient.
  97. Policy/ID number *
    Enter the policy number.
  98. Employer/group name *
    Enter your group name.
  99. Group number *
    Enter your group number.
  100. Member services phone *
    Provide the member services phone number.
  101. Claims address *
    Enter the insurance address.

  102. Third insurance policy

  103. Health insurance name *
    Enter insurance name.
  104. Policy holder first name *
    Enter the first name of the policy holder.
  105. Policy holder last name *
    Enter the last name of the policy holder.
  106. Policy holder birth date *
    Enter the insured's date of birth.
  107. Relationship to patient *
    Enter the relationship to patient.
  108. Policy/ID number *
    Enter the policy number.
  109. Employer/group name *
    Enter your group name.
  110. Group number *
    Enter your group number.
  111. Member services phone *
    Provide the member services phone number.
  112. Claims address *
    Enter the insurance address.

  114. Emergency contact & next of kin

  115. Enter the name of a person you want notified in case of emergency.
  116. Name (first last)*
    Enter your Emergency Contact
  117. Relationship*
    Enter the relationship of your emergency contact.
  118. Main phone*
    Enter the emergency contact's phone number.
  119. Alternative phone
    Invalid Input
  120. Nearest relative*
    Select "same as above" or "other"
  121. Nearest relative's name *
    Enter spouse or nearest
    relative's first name.
  122. Relationship *
    Enter this person's relationship to you.
  123. Main phone number *
    Enter the relative's phone number.
    xxx-xxx-xxxx
  124. Alternative phone number
    Invalid Input

  126. Additional information

  127. 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.


  128. What race best describes you?
    Invalid Input
  129. In what country were you born?
    Invalid Input
  130. What religion do you practice?
    Invalid Input
  131. Would you like us to notify a church of your inpatient stay?*
    Indicate if you want a church notified.

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

  135. 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.


  137.   
 
 
 
 
 
Selected Menu