SEARCH:
September 9, 2010
President's Message
Renaissance Project
Team Behind South Nassau
Patient Registration
Inpatient
Outpatient
Maternity
Online Pre-Registration
Participating Insurance Plans
About Your Stay
Billing
Request Your Medical Records
Visitor's Information
Welcome to South Nassau
Online Registration Form
*
- denotes a required field
Do you have an Advance Directive?
YES
NO
If YES, is it on file with SNCH?
YES
NO
Is this visit related to:
Motor Vehicle Accident?
YES
NO
Work Related Accident?
YES
NO
If YES, please see Registrar for additional required form.
Patient Information
*
Last Name
*
First Name
MI
*
Date of Birth
mm/dd/yyyy
Age
*
Sex
M
F
*
Social Security #
*
Marital Status
M
D
S
W
Translator Needed?
YES
NO
Place of Birth
*
Race
Select:
BLACK
HAWAIIAN/PACIFIC ISLANDER
SPAN/BLACK
SPAN/WHITE
WHITE
OTHER
Religion
Select:
ATHEIST
BAPTIST
BUDDHIST
CATHOLIC
CHRISTIAN
CONGREGATIONAL
EPISCOPAL
GREEK ORTHODOX
HINDU
JEHOVAH WITNESS
JEWISH
LUTHERAN
METHODIST
MUSLIM
NOT PRACTICING
OTHER
PENTECOSTAL
PRESBYTERIAN
SIKH
UNITARIAN
UNKNOWN
Ethnicity
Select:
HISPANIC
NON-HISPANIC
Preferred Language
Mother's Maiden Name
Father's First Name
*
Address
City
State
Zip code
*
Home Tel.#
Cell Phone#
*
Email Address
Emergency Contact Information
*
Emergency Contact Name
Next of Kin Name
*
Relationship
Relationship
Address
Address
*
Tel.#
Tel.#
Employer Information
Patient Employer's Name
Employer's Address
Employer's Tel.#
Employer's Fax#
Patient Retired?
YES
NO
Retire Date
mm/dd/yyyy
Disabled?
YES
NO
Effective Date:
mm/dd/yyyy
Spouse's Name:
Spouse's Retire Date:
mm/dd/yyyy
Primary Insurance
Insurance Name
ID #
Group #
Ins Tel.#
Ins. Billing Address
Policyholder's Name
Relationship to Patient
Policyholder's Employer
Policyholder's DOB
Secondary Insurance
Insurance Name
ID #
Group #
Ins Tel.#
Ins. Billing Address
Policyholder's Name
Relationship to Patient
Policyholder's Employer
Policyholder's DOB
Procedure Information
*
Exam Date
mm/dd/yyyy
Time
Exam Type
Diagnosis
*
Doctor/referring
*
Doctor Phone
Address
Expected Date of Delivery
(if applicable)
mm/dd/yyyy
PLEASE CALL YOUR DOCTOR'S OFFICE AND REQUEST THAT THEY HAVE YOUR PROCEDURE/TEST OR STAY/VISIT AUTHORIZED.
PLEASE HAVE PHOTO I.D. AND ALL INSURANCE CARDS AVAILABLE AT TIME OF SERVICE.
If you have any questions or need help completing this form, please call:
Inpatient/Maternity: (516)632-3901
Outpatient: (516)632-3991
Radiology: (516)632-3211
