PATIENT INFORMATION - Pre-Arrival - 502-7000 Service/Admit Date: * (use 'mm/dd/yyyy' format) Entity/Facility: Saint Francis Hospital Main Campus (Yale) Saint Francis Hospital South Saint Francis Hospital Vinita Saint Francis Hospital Muskogee Saint Francis Hospital Glenpool Helpful Definitions: Pre-Registraion Service Primary Care Physician Living Will Guarantor Subscriber ( * denotes a required field) PATIENT Patient Last Name: * Patient First Name: * Patient M.I.: Prior Legal name: Street Address / PO Box / Apartment Number: * City: * State: * << Select >>AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code: * Home Telephone Number: * Work Telephone Number: Work Extension: Cell/Alternate Telephone Number: Birth Date: * (use 'mm/dd/yyyy' format) Age: Social Security Number: * Gender: * M   F Language: Chinese English French German Spanish Vietnamese Other Race: * << Select >> Asian African American Caucasian Hispanic Native American Other Religion: * Church: * Marital Status: * Divorced Legally Separated Life Partner Married Single Widowed Primary Care Physician: * Physician's Phone: Medical Group: Employment Status: * << Select >> Full Time Part Time Unemployed Retired Employer: * Occupation: * Employer Address: * Employer Phone: * Employer City: * Employer State: * << Select >>AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Employer Zip Code: * Patient Type: Inpatient Outpatient Preference: Private Semi-private Visit Type: << Select >> Inpatient Surgery Outpatient Surgery Pediatrics Maternity Other: Outpatient Service Type (MRI, CT, etc..): Chief complaint / Reason for visit: Accident / Injury: Yes   No Type: << Select >> Motor Vehicle Accident Worker's Comp Other Admitting Physician for this service: Previous patient at any Saint Francis Facility: No   Yes << Select >> Saint Francis Hospital Saint Francis Hospital South Saint Francis Hospital Vinita Saint Francis Hospital Muskogee Saint Francis Hospital Glenpool Warren Clinic Children's Hospital Living Will: Yes   No Please provide daytime phone number if additional information is needed: GUARANTOR Guarantor is self? Yes No EMERGENCY CONTACT Name: * Relationship to Patient: * Home Phone Number: * Work Phone Number: Cell/Alternate Phone Number: Comments: NEXT OF KIN Name: * Relationship to Patient: * Home Phone Number: * Work Phone Number: Cell/Alternate Phone Number: Comments: MEDICARE / MEDICAID COVEREAGE Are you covered by Medicare: Yes No Certificate Number: * Effective Date: * (use 'mm/dd/yyyy' format) Part A: Yes    No Part B: Yes    No Are you covered by Medicaid: Yes No Member ID Number: * Effective Date: * (use 'mm/dd/yyyy' format) PRIMARY INSURANCE Insurance Company Name: Patient's relationship to subscriber: Claims Address: (Address on Card) Telephone Number: City: State: << Select >>AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code: Group: Certificate Number: Effective Date: (use 'mm/dd/yyyy' format) Subscriber's Name: Subscriber's Date of Birth: (use 'mm/dd/yyyy' format) Subscriber's Employment Status: << Select >> Full Time Part Time Unemployed Retired Subscriber's Employer: SECONDARY INSURANCE Insurance Company Name: Patient's relationship to subscriber: Claims Address: (Address on Card) Telephone Number: City: State: << Select >>AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code: Group: Certificate Number: Effective Date: (use 'mm/dd/yyyy' format) Subscriber's Name: Subscriber's Date of Birth (use 'mm/dd/yyyy' format) Subscriber's Employment Status: << Select >> Full Time Part Time Unemployed Retired Subscriber's Employer: OTHER INSURANCE Insurance Company Name: Patient's relationship to subscriber: Claims Address: (Address on Card) Telephone Number: City: State: << Select >>AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code: Group: Certificate Number: Effective Date: (use 'mm/dd/yyyy' format) Subscriber's Name: Subscriber's Date of Birth (use 'mm/dd/yyyy' format) Subscriber's Employment Status: << Select >> Full Time Part Time Unemployed Retired Subscriber's Employer: