Metro Health Pre- Registration

Pre-registration

Step 1 of 5 - General

Step One — Online Pre-Registration and Admission Form

If you have any questions regarding this form, please contact Pre-Arrival at (616) 252-4463.

At Metro Health Hospital, our patients and their families' time and convenience are important to us. Using this pre-registration form will speed up the registration process.

Use this form only if your procedure has already been scheduled.

Please note:
- Complete your pre-registration form at least 24 hours prior to your visit. For your privacy, all information will be sent over a secure connection.
- Upon arrival, patients who use this form need to check in at Registration/Admissions to finalize your registration.
- Please bring the following items:
  - Your insurance cards and photo I.D.
  - Any paperwork from your physician
  - Any forms from your insurance provider
Metro Health Hospital Staff may need to contact you in advance of your scheduled procedure to obtain or provide additional information.

Please read the following important disclosure statement before pre-registration.
1. Notice of Privacy
To view PDF files you'll need to download the free Adobe Acrobat Reader.

This form will take approximately 5 minutes to complete. You will need your insurance card and the patients Social Security number in order to complete the pre-registration process.

By clicking the checkbox you verify:
- You have read and understand the above disclosures
- You are the patient or authorized to act for the patient
- You are at least 18 years of age
Accept*
- I accept

Patient Information
Gender*
Title
First Name*
MI*
Last Name*
Marital Status*
Race*
Ethnicity*
Religious Preference
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
Social Security Number*
Home Phone*
Work Phone
Cell Phone
May We Call You*
Preferred Method
- Home
- Work
- Cell
Email
Patient Employment Information
Employment Status*
Retirement Date
Employer's Name
Employer's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer's Phone

Relative & Emergency Contact Information for Patient
Relationship to patient*
First Name*
MI

Please enter n/a if no middle initial.
Last Name*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Guarantor Information
Does the Patient have a Legal Guardian?
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
Social Security Number
Phone
Guarantor Employment Status
Please change any information below that is not accurate
Employment Status*
Retirement Date
Employer's Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone

Is the patient covered by insurance?*
Primary Insurance Information
Policy Holder relationship to patient*
Policy Holder First Name*
Policy Holder MI*

Please enter n/a if no middle initial
Policy Holder Last Name*
Policy Holder Date of Birth*
MM slash DD slash YYYY
Social Security Number
Employer's Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Contract/ID No*
Group/Plan No
Group Name
Pre-Certification No
Type of Insurance
Name of Insurance Co*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Secondary Insurance Information
Policy Holder relationship to patient
Policy Holder First Name
Policy Holder MI

Please enter n/a if no middle initial
Policy Holder Last Name
Policy Holder Date of Birth
MM slash DD slash YYYY
Contract/ID No
Group/Plan No
Group Name
Pre-Certification No
Type of Insurance
Name of Insurance Co
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Who is your family doctor?*
First Last

(first and last name of your family doctor)
What doctor ordered this test/procedure?*
First Last

(first and last name of physician ordering test or procedure)
Name of Procedure/Test*
Date of Procedure/Test*
Date Symptoms Began
Symptom Details
Do you have an Advanced Directive, Power of Attorney or Living Will regarding your medical wishes? If you do, please bring a copy for inpatient admission*
Do you want this visit marked as private?*
This means you will not be listed in the patient directory so you will not receive phone calls, deliveries, flowers, or visitors. The privacy status can be changed at any time.
If answering yes, the patient will be asked to sign a Confidential Patient Status form during registration. When patients request confidential status, NO information will be given out about this hospital encounter. The patient will not be listed in the hospital directory listing, no visitors directed to the room, no phone calls transferred, no mail and no flower deliveries.
Is the procedure or test you are registering for a result of any accident or injury?*
Medicare Information
Is the patient covered by Medicare?
Is the patient receiving black lung benefits?*
Has the Dept. of Veteran Affairs (DVA) authorized and agreed to pay for care at this facility?*
Is service to be paid for by a government entity, such as a research grant?*
Medicare eligible base on*
Does the patient have group health plan coverage through current employer?*
You're Almost Done
Please review/edit previous answers by clicking on the previous button below on each page. When you are satisfied that the information is correct please click submit below.

If you provided a valid email in Step Two an email confirmation will be sent there stating we received your pre-registration information.

Pre-registration

Step 1 of 5 - General

Step One — Online Pre-Registration and Admission Form

Patient Information

Patient Employment Information

Relative & Emergency Contact Information for Patient

Guarantor Information

Guarantor Employment Status

Primary Insurance Information

Secondary Insurance Information

Medicare Information

You're Almost Done