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Online Patient Pre-Registration

Tallahassee Memorial HealthCare is committed to providing the highest quality medical care possible to all who need and seek our services.  The following pre-registration form will expedite the registration process to make your visit go as smoothly as possible.  

The pre-registration information you submit online is safeguarded by Verisign security certificate and pursuant to legal and regulatory requirements, such as HIPAA, The Health Insurance Portability and Accountability Act.

Please complete the following pre-registration form more than 48 hours before arriving for your appointment.  Review the information and call TMH Pre-Admit at (850) 431-2000 if you have any questions.

PLEASE NOTE:
PLEASE PRE-REGISTER 48 HOURS PRIOR TO YOUR SCHEDULED PROCEDURE


Need Directions? Call (850) 431-5550.

1. Fill Out Form Accurately
When your physician schedules an appointment and you submit this form, our registration office will call you if there are any questions. When filling out the form, please fill out the information as accurately as possible.

2. What to Bring With You
Please be sure to bring the following items with you:

  • Any orders that your physician has given to you
  • Driver's License for ID purposes
  • All of your insurance cards
  • Any co-pay that is applicable to your visit
Have you been a patient at TMH before?    If so, approximately when:
Full Name: Address: 
City:
State: Zip:
Email:
Home Phone: () -
Cell Phone:  () -
Social Security Number
Date of Appointment:
Date of birth (m/d/y): / /
Race:
Gender:
Marital Status:
Religion:
Place of Worship:

Employment Status: If Retired, retirement date: 
Employer:
Address:   
City:
State: Zip:
Occupation:
Phone Number: () - Ext:

Emergency Contact:    Relationship to Patient:
  Address:        
City:
State: Zip:
Home Phone:    ( ) -
Work Phone:    ( ) -  

 Emergency Contact 2:   Relation:
   Address:        
City:
State: Zip:
 Home Phone:    ( ) -
Work Phone:    ( ) -

Complete this section only if Patient is NOT financially responsible
Guarantor:  (person responsible for bill)  
Social Security No.  :
  Employer:     Phone:   ( ) -
  Emp. Address:     City:
State: Zip: Occupation:  

Please copy the following information from your insurance card
Insurance #1:    ID #:    Group #
  Mail Claims Address:    
City:
State: Zip:
Phone Number:    ( ) -
 Pre Cert. Phone:    ( ) -
Benefits Phone:    ( ) -

Insurance #2:    ID #:   Group #
  Mail Claims Address: 
City:
State: Zip:
Phone Number:   ( ) -
  Pre Cert. Phone:   ( ) -
Benefits Phone:   ( ) -

Is this illness/injury due to an accident? What type of accident:
Claim #:
Case Worker Name:
Case Worker Phone:   ( ) -
Type of Registration: Scheduled Date:

Physician who scheduled your appointment:  
Primary Care Physician:  

 
At discharge, do you and your physician anticipate your needing
Do you have a living will?  
Are you an organ donor?  


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