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For Patients

Pre-Registration

Thank you for taking the time to pre-register with St. Mary Medical Center Radiology. Please complete this form in it's entirety at least two days prior to your expected arrival.  AT THE PRESENT TIME, THIS FORM IS FOR RADIOLOGY PATIENTS ONLY.

All fields with an asterisk (*) are required fields.  When finished click 'SUBMIT' at the end of the form.  If you have any questions, feel free to contact Access Operations at 215-710-2041.


* Indicates required information
TESTING / SERVICE INFORMATION 
What date will you be arriving for services? *  (mm/dd/yyyy)
Full Name of Physician or Provider who ordered the test(s) * 
Type of test(s) / procedure needed (please enter what physician has written on the script) * 
Has this test been scheduled ? * 


PATIENT INFORMATION 
Legal Last Name * 
Legal First Name * 
Email Address * 
Reconfirm email address * 
Check here if you want to receive emails about health education classes, health screenings and events * 
Street Address 1 * 
Street Address 2 
City * 
State * 
Zip * 
Country 
Birthday *  (mm/dd/yyyy)
Birthplace of Patient * 
Marital Status * 



If Other, please specify:

Social Security Number  
Religious Preference * 

If Other, please specify:

Gender * 

Race (required for governmental reporting) * 






If Other, please specify:

Home Telephone Number  * 
Is it OK to leave a message at this phone number? * 

Cell Phone or Alternate Phone Number 
In what language do you prefer your medical care? * 


If Other, please specify:

Name of Family Physician or Primary Care Doctor * 
EMPLOYMENT INFORMATION 
Employment Status * 






If Other, please specify:

Employer Name * 
Employer Phone Number  * 
Employer Address * 
PRIMARY INSURANCE INFORMATION 
Do you carry group insurance through the above employer? * 
Name of Insurance Policy Holder * 
Primary Insurance Company Name * 
Insurance ID # * 
Group Number 
Precertification Number 
Insurance Referral Number 
SECONDARY INSURANCE INFORMATION 
Secondary Insurance Company Name 
Name of Policy Holder 
If insurance policy holder is different from the patient, provide relationship 
Insurance ID # 
Insurance Group # 
Who is responsible for the bill after insurance has paid? * 
If Auto insurance is primary, we require your medical insurance information in the secondary insurance company fields 
Complete only if test ordered is due to an auto or work injury 

What is the date of the accident  (mm/dd/yyyy)
FOR MEDICARE PATIENTS ONLY 
Do you receive Black Lung medical benefits ? * 
Are you entitled to Medicare based on 
Will you services be paid bt a government program other than Medicare/Medicaid? * 
EMERGENCY CONTACT INFORMATION 
Name of Emergency Contact * 
Relationship of emergency contact * 

If Other, please specify:

Telephone number of emergency contact * 
Address of emergency contact * 
City of emergency contact * 
State of emergency contact * 
NEXT OF KIN INFORMATION 
Is your Emergency Contact also your Next of Kin ? * 

If no, please answer the next six questions, Next of Kin Complete Name * 
Next of Kin Relationship * 
Next of Kin Address * 
Next of Kin City * 
Next of Kin State * 
Next of Kin Telephone Number * 
Authentication * 

If the challenge words are too difficult to read, click here to refresh.
 

Thank you for submitting your pre-registration information.
If you have any questions, feel free to contact Access Operations at 215-710-2041.

REMEMBER to bring photo ID and your insurance card on your testing day.