Pre-Registration


Pre-registration is available on-line for maternity, mammography and outpatient lab at any time of the day or night. Patients who pre-register will be asked to verify their information when they arrive, sign consent forms, provide copies of their insurance cards and ID and make any necessary payments. Pre-registered patients should report to the designated pre-registration area, to the right of the information desk.

Please remember to bring all insurance and medical cards, as well as any written orders given to you by your physician, with you on your visit to our hospital. In order to complete the on-line registration, please have the following items available: insurance Information (if insured) and Social Security Numbers for the Patient and/or the primary on the insurance plan.

You may be contacted if there are questions about your information, or asked for further information upon your arrival.

Thank you for using our online pre-registration. If you have questions or concerns regarding the registration process, or if you need to make changes to your submission, please contact us at (812) 949-5942.

Registrations can only be accepted for appointments on Fri, May 29 2015 16:04:25 EDT or later

* To pre-register for mammography you must have an appointment scheduled

All fields are required, except for fields marked as optional.

05/28/2015
MM/DD/YYYY
MM/DD/YYYY
First and last name
First and last name
MM/DD/YYYY
Example: 3:00 pm
First and last name
First and last nameoptional

Patient's Information

optional
Patient: Please list both parent's names either living or deceased for security measures.
Yes
Residential Address
Billing Address
XXX-XXX-XXXX
XXX-XXX-XXXX
optional
MM/DD/YYYY
XXX-XX-XXXX
Please specify

Current Smoker
Former more than 1 year
Former more than 5 years
Former more than 10 years

Yes
XXX-XXX-XXXX

Spouse or Significant Other

optional
Same as patient's address
XXX-XXX-XXXX
MM/DD/YYYY
XXX-XX-XXXX
XXX-XXX-XXXX

Nearest Relative/Emergency Contact Not Living At Your Address

XXX-XXX-XXXX

Insurance

Please fill in all information and bring your insurance card with you on your date of service.

XXX-XXX-XXXX
Same as patient
MM/DD/YYYY
XXX-XX-XXXX
XXX-XXX-XXXX
Same as patient
MM/DD/YYYY
XXX-XX-XXXX

Please contact the financial office for information regarding payment plans or the short stay OB program at (812) 949-5726 and (812) 981-7289.

If you have an Advance Directive/Living Will, please bring it with you on the day of admission.
If you have any questions, please call Patient Registration at (812) 949-5942.

Enter Verification Code: