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

* First Name:Add your first name

* Last Name:Add your last name

Preferred Name:Add your preferred name

* Social Security Number:Add your social security number

* Date of Birth:Add your birthday (mm/dd/yyyy)

* Sex:Choose your sex - Select - Male Female

* Address:Add your address

* City:Add your city

* State:Choose your state - Select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

* Zip:Add your zip code

* Primary Phone:Add your primary phone - Select - Home Phone Work Phone Cell Phone

Secondary Phone:Add your secondary phone - Select - Home Phone Work Phone Cell Phone

* Email Address:Add your email address

* Marital Status:Choose your marital status - Select - Divorced Legally Separated Married Significant Other Single Widowed

* Ethnic Group:Choose your ethnic group - Select - Chooses Not to Answer Hispanic or Latino Not Hispanic or Latino

* Race:Choose your race - Select - African American American Indian/Eskimo Asian Caucasian Chooses Not to Answer Hispanic/Latino Middle Eastern Indian Native Hawaiian/Other Pacific Islander Two or More Races Unknown

Insurance Information

* Are you insured? - Select - Yes No

* Insurance Provider:Choose insurance provider - Select - Medicaid Medicare Other

* Other Insurance Provider:Add provider name

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.

* Are you receiving Black Lung (BL) Benefits?Choose - Select - Yes No

* Are services to be paid by a government research program?Choose - Select - Yes No

* Are you entitled to benefits through the Department of Veteran Affairs (DVA)?Choose - Select - Yes No

* Was the illness/injury due to a work related accident/illness?Choose - Select - No Accident Illness

* Are you entitled to Medicare based on age?Choose - Select - Yes No

* Are you entitled to Medicare based on disability?Choose - Select - Yes No

* Are you entitled to Medicare based on End-Stage Renal Disease (ESRD)?Choose - Select - Yes No

* Member ID:Add your policy member id

Group Number:Add your policy group number

* Policyholder Name:Add your policyholder name

Financially Reponsible Party Employment Information

* Is the financially responsible party employed?Choose - Select - Yes No

* Employer:Add employer name

* Employment Status:Choose status - Select - Full-time Part-time

Employer Address:Add employer address

Employer City:Add employer city

Employer State:Choose employer state - Select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Employer Zip:Add employer zip code

Employer Phone:Add employer phone

Patient Employment Information

* Patient is the financially responsible party?Choose - Select - Yes No

* Is the Patient employed?Choose - Select - Yes No

* Employer:Add employer name

* Employment Status:Choose status - Select - Full-time Part-time

Employer Address:Add employer address

Employer City:Add employer city

Employer State:Choose employer state - Select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Employer Zip:Add employer zip code

Employer Phone:Add employer phone

Service Information

* Ordering Physician:Add physician name

* Hospital:Choose hospital - Select - Atrium Medical Center Good Samaritan Hospital Miami Valley Hospital Upper Valley Medical Center

* Expected Date of Service:Add date of service

* Date Symptoms Began:Add date symptoms began

* Is your condition due to an accident or injury?Choose - Select - Yes No

Procedure:Add procedure

Diagnosis:Add diagnosis

Register

Review Your Information

Please review the information you have provided before submitting your request.

You must click on the submit button below to complete your registration.

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Thank You

Thank you for registering for your service with us. To better serve you, we will will verify your insurance and contact you if you have any co-pay, coinsurance or deductible.

If you have questions or concerns, you can call (937) 499-7364 for more information.

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