Memorial Hermann Patient Registration Information:
 Heart & Vascular Institute

*Indicates a required field. See gray shaded boxes for more instructions.

     
Patient Information

If using your insurance, please complete name below exactly as it appears on your insurance card.
If private pay, please complete using your legal name.

*Last Name
*First Name  *Middle Initial
[If no Middle Initial, check this box: ]
*Street Address Apt. No.  
 
*City *State *Zip Code
      
*Home Telephone E-mail Address
-
     
*Social Security Number If no Social Security Number, please indicate reason below: 
- -  
     
*Sex *Birthdate
Female  Male MM/DD/YYYY
       
*Race (State Requirement)    *Hispanic Origin (State Requirement)
Yes         No
             
*Marital Status  
Married  Divorced  Single Widow
           
*Primary Language: Religion
      
*Employment Status    
Full-Time      
Part-Time      
Retired; Retirement Date: MM/YYYY
Unemployed        
        
If Full-Time or Part-Time, the Occupation and Employer information below is required.
If Retired, please fill in the previous Employer and Work Telephone.
*Occupation    
   
*Employer *Work Telephone
   -
*Street Address    
   
*City *State *Zip Code
       
          
Guarantor/Insured Information

Guarantor or Insured is the person whose insurance will cover you. If private pay, provide responsible party's information.
   

* Please indicate who is financially responsible for patient's account:
           
*Last Name
*First Name  *Middle Initial
[If no Middle Initial, check this box: ]
*Street Address Apt. No.  
 
*City *State *Zip Code
      
*Home Telephone *Social Security Number
- - -
       
*Sex *Birthdate  
Female  Male MM/DD/YYYY
         
*Employment Status  [If Private Pay, check this box: ]
Full-Time        
Part-Time      
Retired; Retirement Date: MM/YYYY    
COBRA Coverage    
       
If Full-Time or Part-Time, the Guarantor's Occupation and Employer information below is required.
If Retired, please fill in the Guarantor's previous Employer and Work Telephone.
If COBRA Coverage, please fill in the Guarantor's Employer and Work Telephone of employer who is providing the coverage.
*Occupation      
     
*Employer     *Work Telephone
    -
*Street Address    
   
*City *State *Zip Code
              
Insurance/Payment Information
 
*Select one:      
Insurance Cash Check Credit Card
     
If not using insurance, the remaining Insurance/Payment Information section is not required. You may skip to Next of Kin.
*If insurance, what is Plan Type?  
 
          
Primary      
*Plan Name *Name of Insured
*Member ID/Policy # *Insured's Relationship to Patient
Group # is required if insurance is HMO, PPO, POS, EPO, Indemnity, or Worker's Comp.
*Group #   
 
   
The insurance mailing address section below is required if insurance is HMO, PPO, POS, EPO, Indemnity, Worker's Comp, Medicaid HMO, or Medicare HMO.
*Mail Claim To (usually printed on back of insurance card) 
 
*Street Address        
    *Member/Customer Service
Phone Number
*City *State *Zip Code
-
         
Secondary      
Plan Name Name of Insured
Member ID/Policy # Insured's Relationship to Patient
Group #  
 
Mail Claim To (usually printed on back of insurance card) 
 
Street Address      
  Member/Customer Service
Phone Number
City State Zip Code
-
               
Next of Kin
  Check box if same as Guarantor/Insured.  
     
*Relationship to Patient  
 
*Last Name
*First Name  Middle Initial
*Street Address Apt. No.  
 
*City *State *Zip Code
*Home Phone Work Phone
- -
       
Emergency Contact Information
Check box if same as Next of Kin.  
   
*Relationship to Patient  
 
*Last Name
*First Name  Middle Initial
*Street Address Apt. No.  
 
*City *State *Zip Code
*Home Phone Work Phone
- -
         
Clinical Information
*This visit is related to (select one):

Pregnancy: C-Section
Pregnancy: Vaginal Delivery
Illness
Diagnostic Testing/Procedure
Accident
   
If accident, Date & Time of accident:

at

:   AM PM  
If accident, please select type:
   
*Diagnosis or Chief Complaint
Primary Care Physician is required if insurance is HMO, Medicaid HMO, or Medicare HMO.
*Primary Care Physician (PCP) or Family Physician
Last Name, First Name
Would you like your information regarding your visit made available to your OB/Primary Care Provider?
Yes  No 
*Admitting/Attending/Ordering Physician
Last Name, First Name
* Date of Procedure *Type of Surgery/Procedure
MM/DD/YYYY
                  

If any of the above information changes before your surgery/procedure, please notify the hospital's Business Office.

Please print a copy for your records. (See below for help with printing.)
Press Submit to e-mail this information to the Business Office for processing.

  

 
Print:

If you have a printer, you may use the Print function on your browser to retain a copy for your records. After you have finished filling out the form, click on the File menu button at the top of your browser and select Print. A copy of your completed form will print out.

For best results, make sure your browser text size is set to Medium (or a Times New Roman, size 12 font).
Fax: Alternatively, you may fax a printed copy to the Business Office at 713-778-6214.
MEMORIAL HERMANN HEALTHCARE SYSTEM   Houston, Texas     70307 3/99