Patient Pre-Registration

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Jewish Hospital & St. Mary's HealthCare offers on-line pre-registration for all patients scheduled for outpatient surgery, endoscopy, diagnostic and invasive services at the following facilities:

  • Jewish Hospital Outpatient Care Center
  • Jewish Hospital Medical Center East
  • Jewish Hospital Medical Center Northeast
  • Jewish Hospital Medical Center South
  • Jewish Hospital Medical Center Southwest
  • Jewish Hospital Shelbyville
  • Sts. Mary & Elizabeth Hospital

Pre-Registration hours are 9:00 a.m. to 9:00 p.m. Monday - Friday. Online pre-registration must be submitted 24 hours in advance of procedure.

Please complete and submit the form below to pre-register for your visit. If you need additional assistance, please call Jewish Hospital Outpatient Registration at (502) 587-4698.

Many insurance companies require either a pre-certification number or a physician referral. Please check with your insurance company to ensure that appropriate authorization has been obtained for your procedure.

Patient Information

Where is your appointment?





* Name:
   
FIRST   MI   LAST
Maiden Name:
* Address:
* City:
* State:
*Zip: ex. #####
Home Phone: ex. xxx-xxx-xxxx
* Email:
May we respond to you via email?
SSN #:
Date of Birth: ex. MM/DD/YYYY
Religion:
Are you allergic to latex? (or any natural rubber products i.e. physician gloves)
Race:


Sex:
Marital Status:


Spouse's Name:
* Primary (Family) Doctor:
Do you have a living will or health care surrogate?
Have you ever had an organ transplant?
Have you ever been a patient at Jewish Hospital?
Patients Employer:
Employment Status:
Address:
Work Phone Number: ex. xxx-xxx-xxxx
City:
State:
Zip Code: ex. #####
Position:
Date of arrival:
Physician ordering test?
Referring Physician (who sent you to the doctor ordering the test)?
What are you coming for?

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© 2013 KentuckyOne Health
200 Abraham Flexner Way•Louisville, KY•40202

Last Updated: 9/6/2013