Pre-Registration Form

To register for a service or procedure with a Premier Health hospital, you can either call (937) 499-7364 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

You will receive an email confirming that we have received your registration. We are aware that email is not considered a secure means of communication, so the confirmation email will not contain any identifying health information.