Welcome to HealthAlliance Web Pre-Registration

Please fill out the form listed below. Fields with red text are required fields.


  Patient Information

First Name
Last Name
Middle Initial
Place of Birth
Date of Birth
Social Security Number
Address
City
State
Zip Code
Country
Gender
Race
Ethnicity
Preferred Language
Preferred Phone Number
Cell Phone Number
Email Address

Emergency contact Information

First Name
Last Name
Date of Birth
Address
City
State
Zip Code
Country
Preferred Phone Number
Cell Phone Number
Email Address
Relationship to Patient

Guarantor - *Must be completed if patient is less than 18 years of age*

Check here if above Emergency contact is the patient's guarantor.
Complete below if different from Emergency contact
First Name
Last Name
Address
City
State
Zip Code
Country
Preferred Phone Number
Cell Phone Number
Relationship to Patient

Primary Care Physician

First Name
Last Name

Related to Incident, injury or illness

No     Yes - If yes please fill out below.
Begin date of incident, injury or illness
Description of incident, injury or illness
State of incident, injury or illness

Insurance Information

Is the patient insured?

Yes
No
Primary Insurance Company Name
Member ID or Policy Number
Group Number (if available)
Subscriber to Policy
Insurer's Phone number Is found on the back of the card
Complete for Motor Vehicle and Workers Compensation Insurances
Insurer's Address
City
State
Zip Code
Country
Secondary Insurance Company Name
Member ID or Policy Number
Group Number (if available)
Subscriber to Policy
Insurer's Phone number Is found on the back of the card
Complete for Motor Vehicle and Workers Compensation Insurances
Insurer's Address
City
State
Zip Code
Country

Appointment/Procedure Information

Appointment or Service Date

If you encounter any issues completing this form, please call 978-466-4777, option 1 between the hours of  7am and 5pm.

 

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Copyright 2012 [HealthAlliance Hospital]. All rights reserved.                
Revised: October 23, 2012