Pre-Registration Form

To register for a service or procedure with a Premier Health hospital, you can either call (937) 499-7634 or fill out the following secure online form.

Patient Personal Information


















Insurance Information





You selected Medicare as your insurance provider. Please answer the following questions regarding your benefits. Based on your answers, you may receive a call from Premier Health to complete the pre-registration process.



Financially Reponsible Party Employment Information







Patient Employment Information








Service Information