Step 1 of 8 : Visit / Procedure Information

In this step, you must provide some basic information about the patient's visit to Northside Hospital.

Fields whose names appear in red* are required.

Patient financial liability (applicable co-pay, co-insurance and deductible) is due prior to services rendered.

PLEASE BE PREPARED TO PROVIDE A COPY OF YOUR DRIVER'S LICENSE AND INSURANCE.

 

 

Is this accident related?

Is this work related?

Step 2 of 8 : Patient Information

In this step, you must provide some basic information about the patient's visit to Northside Hospital.

Fields whose names appear in red* are required.

PLEASE BE PREPARED TO PROVIDE A COPY OF YOUR DRIVER'S LICENSE AND INSURANCE.


Check here if interpreter requested.

Enter language

Address Line 1 *

Address Line 2

City *

State *

Zip *

Ok to leave a message?
 Yes  No



Employer Address Line 1

Employer Address Line 2

Employer Address City

Employer Address State

Employer Address Zip

Have you been seen previously at any of our Northside Hospital locations?
If yes, what location? 
If yes, have you been seen under a different name? 

Step 3 of 8 : Accident Information

In this step, you must provide some basic information about the patient's accident.

Fields whose names appear in red are required.

PLEASE BE PREPARED TO PROVIDE A COPY OF YOUR DRIVER'S LICENSE AND INSURANCE.

Accident Type *

Accident Date *

County Of Accident *

Nature of Accident *

Insurance Company Name *

Insurance Company Address Line 1 *

Insurance Company Address Line 2

Insurance Company City *

Insurance Company State *

Insurance Company Zip code *

Insurance Claim # *

Step 4 of 8 : Emergency Contact

In this step, you must describe a person who is the emergency contact for the patient.

Fields whose names appear in red are required.

PLEASE BE PREPARED TO PROVIDE A COPY OF YOUR DRIVER'S LICENSE AND INSURANCE.

Step 5 of 8 : Policy Holder

In this step, you must provide some basic information about the primary insurance policy holder.

Fields whose names appear in red are required.

Please enter all information exactly as it appears on your insurance card.

PLEASE BE PREPARED TO PROVIDE A COPY OF YOUR DRIVER'S LICENSE AND INSURANCE.

Enter relationship


Address Line 1

Address Line 2

City

State

Zip



Employer Address Line 1

Employer Address Line 2

Employer City

Employer State

Employer Zip

Step 6 of 8 : Primary Insurance Information

In this step, you must provide some basic information about the primary insurance policy under which the patient is covered.

Fields whose names appear in red are required.

Would you like to add a secondary insurance policy?

PLEASE BE PREPARED TO PROVIDE A COPY OF YOUR DRIVER'S LICENSE AND INSURANCE.

Are you enrolled in Amerigroup, Peachstate or Wellcare or any other Medicaid HMO plan?  Yes  No

*

Is your plan a Medicare Advantage product?  Yes  No

*

To obtain a price estimate, please call our Price Estimate Line at 404-851-8694 or email at price.estimate@northside.com.

Address Line 1

Address Line 2

City

State

Zip

Is Precertification Required?

I have a secondary insurance policy

Step 7 of 8 : Secondary Insurance Information

In this step, you must provide some basic information about the primary insurance policy under which the patient is covered.

Fields whose names appear in red are required.

PLEASE BE PREPARED TO PROVIDE A COPY OF YOUR DRIVER'S LICENSE AND INSURANCE.

Are you enrolled in Amerigroup, Peachstate or Wellcare or any other Medicaid HMO plan?  Yes  No

*

Is your plan a Medicare Advantage product?  Yes  No

*

To obtain a price estimate, please call our Price Estimate Line at 404-851-8694 or email at price.estimate@northside.com.

Address Line 1

Address Line 2

City

State

Zip

Is Precertification Required?

Step 8 of 8 : Workers Compensation Information

In this step, you must provide some basic information about the patient's visit to Northside Hospital.

Fields whose names appear in red are required.

PLEASE BE PREPARED TO PROVIDE A COPY OF YOUR DRIVER'S LICENSE AND INSURANCE.

Employer Address Line 1 *

Employer Address Line 2

Employer Address City *

Employer Address State *

Employer Address Zip *


Claims Address Line 1 *

Claims Address Line 2

Claims Address City *

Claims Address State *

Claims Address Zip *

Terms and Conditions

Patient financial liability (applicable co-pay, co-insurance and deductible) is due prior to services rendered.

In order to complete your pre-registration, please confirm that you have fully read and understand Northside Hospital's HIPAA Privacy Statement and Website Privacy Policy.

I have read and accept Northside Hospital's Privacy Policy and acknowledge receipt.

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NOTE: For directions, you may call our Directions Line at (404) 303-3900 or visit the Locations section on the home page of this web site. To cancel your appointment, please contact your physician's office or the scheduling department where you originally made your appointment. If you would like to contact the pre-registration department, you may do so at (404) 459-1280.

If you would like to receive an estimate of your liability for this service, please contact our Priceline at 404-851-8694 or email your request to price.estimate@northside.com.


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