Pre-Registration for Delivery at Logan Health

Pre-Registration for Delivery at Logan Health

Patient Information

Your Legal First Name*

Your Legal Last Name*

Your Middle Initial

Your previous name if applicable

Are you currently or have you ever been a patient at Logan Health?*

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Your Birthdate*

Mailing Address*

City*

State*

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Zip Code*

Email Address*

Best Contact Phone Number*

Marital Status

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Social Security Number (Used for identification purposes only)

Admission Information

Where do you plan on delivering?*

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Due Date

Delivery Method

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First name of care provider who will deliver your baby

Last name of care provider who will deliver your baby

First name of primary care physician

Last name of primary care physician

Do you have a pediatrician?

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Pediatrician's Name (First and Last Name, please)

Would you like help in finding a pediatrician?

Select

Employment Information

Employment Status

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Employer's Name (if applicable)

Employer's Address/PO Box

Please include the street address, city, state and zip code.

Work Phone Number

Occupation

Emergency Contacts

Please list the name(s) of your emergency contact(s). These can include a spouse/partner, family member, friend, or a parent/legal guardian (if patient is a minor).

Contact 1: Legal Last Name

Contact 1: Legal First Name

Contact 1: Middle Initial

Contact 1: Relationship to Patient

Contact 1's address is same as patient's address

Contact 1: Mailing Address

Please include the street address, city, state and zip code.

Contact 1: Phone Number

Contact 2: Legal Last Name

Contact 2: Legal First Name

Contact 2: Middle Initial

Contact 2: Relationship to Patient

Contact 2's address is the same as patient's addre

Contact 2: Mailing Address

Please include the street address, city, state and zip code.

Contact 2: Phone Number

Insurance Information

Please bring your insurance cards with you on the day of your admission. As a reminder, most insurance providers require that pre-authorization be obtained prior to services being rendered. With this in mind, it is your responsibility to check in with your insurance provider to ensure that your visit will be covered and to see whether pre-authorization or other requirements need to be met prior to services being rendered. If a prior authorization is required, you must work with your physician office to obtain it prior to admission.

Does the patient have insurance?

Select

Primary Insurance: Insurance Company Name

Your primary insurance company pays first.

Policy Holder's Name (First and Last Name)

Policyholder Birthdate

Policyholder's Relationship to Patient

Primary Insurance: Insurance Address

Please include the street address, city, state and zip code.

Primary Insurance: Policy/Subscriber Number

Primary Insurance: Group/File Number

Primary Insurance: Type of Plan

Select

If group plan, name of employer providing coverage

Has your stay been authorized by your insurance company?

Select

Secondary Insurance: Insurance Company Name

Policyholder's Name (First and Last Name)

Secondary Insurance: Policyholder Birthdate

Policyholder's Relationship to Patient

Secondary Insurance: Insurance Address

Secondary Insurance: Policy/Subscriber Number

Secondary Insurance: Group/File Number

Secondary Insurance: Type of Plan

Select

Has your stay been authorized by your insurance company?

Select

Advanced Medical Directives

Please note: Having an Advanced Medical Directive on file for your upcoming admission is optional. Should you decide that you would like to have one, please bring the completed copy with you and present it at the time of your admission or send it to Logan Health Medical Center prior to your admission. If you would like to download Advanced Medical Directive forms for completion, visit our Advance Medical Directives section. If you would like more information on Advanced Medical Directives, or would like paper versions of the forms sent to you, please call (406) 752-1740.

Do you wish to be added to the Patient Directory (census)?

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Do you have an Advance Medical Directive? (Living Will or Power of Attorney for Healthcare)

Select

Current location of Advanced Medical Directive

Other Information

We are required by the State of Montana to obtain data regarding race and ethnicity on every patient we register. These categories are dictated by the State of Montana. Please mark both your race and ethnicity below:

Patient's Race

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Patient's Ethnicity

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Primary Language

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Other language

Will you need an interpreter?

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Religious Preference

Logan Health would like to record your religious preference to assist you in your spiritual care should the need occur. We will record this information in your permanent hospital record.

Additional Comments

Is there any additional information that you would like us to know regarding your upcoming admission?

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