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Please read all of these instructions carefully before beginning your pre-registration. McLeod Health is pleased to offer a convenient and secure way for our patients to pre-register for upcoming hospital services. By completing this questionnaire, we will be able to verify all demographic and insurance information before you arrive, so that most or all of your paperwork will be complete on the day of your appointment.

Ways to Pre-register
For your convenience we offer three different ways for you to pre-register for an upcoming service at any of our McLeod Health facilities. You can complete the online pre-registration form here, or you can call our Pre-registration service at 1-800-667-2005 or 843-777-2095. McLeod Reservations & Scheduling is available to complete your pre-registration by phone Monday through Friday from 8am until 5pm. You can also stop by your McLeod facility and complete your pre-registration in person. Please remember that web pre-registration should be completed at least two business days prior to your hospital service. Business days do not include weekends or holidays.

If your procedure is scheduled less than two business days from today, please call us to complete your pre-registration by phone.

Please have the following information available when you complete the form or if you call to pre-register.

    • Patient information including date of birth, social security number and demographic information
    • Test, procedure or service you are having done
    • Physician's name
    • Date and time of appointment
    • Location of appointment
    • Insurance cards - click here to go to our managed care information page

Benefits of Pre-Registration

    • Allows us to communicate with your insurance company to verify your benefits and eligibility, complete pre-certification requirements, obtain referrals or pre-authorization (if required) and resolve any insurance questions before you arrive.
    • Allows us to communicate with you regarding financial obligations before your test to help you plan.
    • Eliminates service delays by allowing you to pay your co-pays or deductibles before your service. We are able to process credit card payments by phone.
    • Eliminates worry and confusion over hospital bills after your discharge.

The information that you provide to us online is transmitted only to designated pre-registration personnel in the McLeod Reservations & Scheduling Department where your account will be confidentially created.

If you have concerns about using this online feature, please contact the Reservations & Scheduling department at (843) 777-4301 or the McLeod HIPAA Privacy Officer at (843) 777-2485.

If you have any questions about an appointment or services offered through McLeod Health, please call us at 1-800-667-2005 or 843-777-2095 and follow the prompts. We look forward to hearing from you.

Step One
What Type of Patient?
Inpatient Outpatient OB Patient
If OB Patient, please give due date:
Where will the procedure be performed?
McLeod Regional Medical Center
McLeod Medical Center - Dillon
McLeod Medical Center - Darlington
Mobile Mammography Van
Date of appointment
NOTE: Pre-Registration by web is not allowed within 48 hours of the test or exam
What procedure/test are you pre registering for?

What symptoms are you currently experiencing?
Procedure Time:

Patient's Doctor's Name
Patient's Information*
First Name
 Last Name
 Middle or Maiden Name
Patient's Address*
Street
 City
State
 Zip
Patient's Social Security Number:
Patient's Phone Number:
Home:

 Work/Cell:
Date of Birth*:
Month
 Day
 Year
Marital Status
 Sex
 Religion

 Race
Do you smoke or use tobacco products?
No Yes

If you have any special needs, check all that apply:
Blind Deaf Interpretor Equipment

Step Two
Have you stayed at any McLeod medical facility previously?
McLeod Regional Medical Center When:

Under What Name:
McLeod Medical Center - Dillon When:

Under What Name:
McLeod Medical Center - Darlington When:

Under What Name:
Step Three
Patient's Mother's Maiden Name
Patient's Employer
 Employer's Phone Number
In case of emergency, notify
 Relationship to Patient
Emergency Notification Address
Emergency Notification Phone Number (Include Area Code)
Guarantor's Name
(Who is responsible for bill payment)
  
Guarantor's Social Security Number
  
Date of Birth
Month Day Year
Guarantor's Address (If different from above)
Guarantor's Phone Number
  
Guarantor's Employer
 Employer's Phone Number
Step Four
Do you have Medicare?
No Yes, please give number
Do you have Medicaid?
No Yes, please give number
Name of your hospital Insurance (Please list all insurance companies)
Name of Insurance Company

Insurance Co. Address

Insurance Co. Phone

Insured Social Security Number

Policy Number

Group Number

Subscriber

Name of Insurance Company 2

Insurance Co. 2 Address

Insurance Co. 2 Phone

Insured 2 Social Security Number

Policy Number 2

Group Number 2

Subscriber

Name of Insurance Company 3

Insurance Co.3 Address

Insurance Co. 3 Phone

Insured 3 Social Security Number

Policy Number 3

Group Number 3

Subscriber
Step Five
Additional Information:
Email Address

Please indicate a number and the best time for a representative
to contact you to confirm your pre-registration.
Phone Number
 Time To Call

 
     
  The Gold Seal of Approval
The information on this site is intended to increase your awareness and understanding of specific health issues and services at McLeod Health.
It should not be used for diagnosis or as a substitute for health care by your physician.
To report technical issues, please contact us. Public Access to Information or To Report a Concern.
©2007-2008 McLeod Health. HIPAA Notice of Privacy Practices | Patient Bill of Rights | Report a Concern