Doctors hand writing in patents chart.

MRMC Online Pre-Registration Form

Step 1 of 5

Pre-Register
  1. What Type of Patient?
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  2. If OB Patient, please give due date:
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  3. Where will the procedure be performed?
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  4. Date of appointment

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    NOTE: Pre-Registration by web is not allowed within 48 hours of the test or exam
  5. What procedure/test are you pre registering for?
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  6. What symptoms are you currently experiencing?
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  7. Procedure Time:
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  8. Patient's Doctor's Name
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  9. Patient's Information
  10. First Name(*)
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  11. Last Name(*)
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  12. Middle or Maiden Name(*)
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  13. Patient's Address*
  14. Street(*)
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  15. City(*)
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  16. State(*)
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  17. Zip(*)
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  18. Patient's Social Security Number:
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  19. Patient's Phone Number:
  20. Home:
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  21. Work/Cell:
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  22.  
  1. Have you stayed at any McLeod medical facility previously?
  2. McLeod Regional Medical Center
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  3. When
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  4. Under What Name
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  5. McLeod Medical Center - Dillon
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  6. When
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  7. Under What Name
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  8. McLeod Medical Center - Darlington
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  9. When
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  10. Under What Name
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  11.  
  1. Patient's Mother's Maiden Name
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  2. Patient's Employer
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  3. Employer's Phone Number
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  4. In case of emergency, notify
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  5. Relationship to Patient
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  6. Emergency Notification Address
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  7. Emergency Notification Phone Number
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    (Include Area Code)
  8. Guarantor's Name
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    (Who is responsible for bill payment)
  9. Guarantor's Social Security Number
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  10. Date of Birth

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  11. Guarantor's Address
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    (If different from above)
  12. Guarantor's Phone Number
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  13. Guarantor's Employer
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  14. Employer's Phone Number
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  15.  
  1. Do you have Medicare?
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  2. Medicare Number
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  3. Do you have Medicaid?
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  4. Medicaid Number
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  5. Name of your hospital Insurance (Please list all insurance companies)
  6. Name of Insurance Company
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  7. Insurance Co. Address
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  8. Insurance Co. Phone
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  9. Insured Social Security Number
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  10. Policy Number
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  11. Group Number
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  12. Subscriber
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  13. Name of Insurance Company 2
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  14. Insurance Co. 2 Address
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  15. Insurance Co. 2 Phone
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  16. Insured 2 Social Security Number
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  17. Policy Number 2
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  18. Group Number 2
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  19. Subscriber
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  20. Name of Insurance Company 3
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  21. Insurance Co.3 Address
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  22. Insurance Co. 3 Phone
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  23. Insured 3 Social Security Number
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  24. Policy Number 3
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  25. Group Number 3
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  26. Subscriber
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  27.  
  1. Additional Information:
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  2. Email Address(*)
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  3. Please indicate a number and the best time for a representative to contact you to confirm your pre-registration.
  4. Phone Number(*)
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  5. Time To Call(*)
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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.

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