Doctors Hospital at Renaissance - Pre-Registration Form

Online Direct Admit Pre−Registration Form

* Fields marked in red are required.

To make your registration at DHR as fast and easy as possible, please complete and submit the following pre-registration form.
This form shall only be utilized for direct admit patients to DHR and shall, under no circumstance, be utilized for any emergency patient cases. In the event of an emergency patient case, please send the patient directly to the Emergency Room.
Please be sure to enter all direct admit patient information correctly. DHR shall not be responsible for any delays in the registration process that may result from the incorrect submission of any information through this system.
Please be advised that this form will only serve to pre-register direct admit patients. The Physician Office will be required to call DHR Bedboard prior to use of this system and patients will still be required to personally present to DHR with personal identification and insurance information to fully register prior to admission at DHR.
Please note that completion and submission of this form does not guarantee admission or a bed at DHR.

Patient information Please enter full legal name.
Last Name	First Name	Middle Name
Address	City	State	Zip
County	Phone - -	Primary Language Spoken
Social Security Number	Date of Birth	Gender MaleFemale
Race	Marital Status	Religion
Visit Type InpatientOutpatientObservationPre-Registration	Have the patient been here before YesNo

service/procedure information Please enter information regarding the patient’s stay.
Procedure / Test	Date of Procedure	Diagnosis
Admitting Physician Last Name	Admitting Physician First Name	Family Physician Last Name	Family Physician First Name

insurance information If uninsured, please type "none" in the insurance Company Name.
Insurance Company Name	Insurance Company Phone Number - -	Insurance Policy Number	Insurance Group Number

contact information We will contact you within 30 minutes of receiving this information to provide a visit ID. Please enter your contact information.
Name: Organization:	Phone - - Or E-mail	Temporary Room Assigment Comments:

We protect the personal information we have collected from this site by using industry standard security precautions against loss and unauthorized access, distribution, use modification or disclosure of information.

We comply with the security and safeguards detailed in our computer security policies and procedures and routinely monitor that compliance.

For more information, please see our Notice of Privacy Practices.

Doctors Hospital at Renaissance proudly meets the federal definition of a “physician-owned hospital (42 CFR § 489.3).