PRE-REGISTRATION-Genetics-Website

PRE-REGISTRATION
Department of Medical Genetics and Genomic Medicine

Telephone: 732.745.6659

Fax Number: 732.249.2687
- Patient's Full Legal Name*
  
  First NameLast Name
- Patient's Date of Birth*
  
  MonthDayYear
- Is the Patient a Minor?*
  
  YesNoHas an Authorized Legal Representative
- Authorized Legal Representative
  
  First NameLast Name
- Description of Authority
  i.e. Parent, Ward of State, etc.
- Patient's Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Phone Number*
  
  Area CodePhone Number
- Other Phone Number
  
  Area CodePhone Number
- Does the Patient/Authorized Legal Representative have an email address?*
  
  YesNo
- Patient/Authorized Legal E-mail*
- Patient's Marital Status*
- Patient's Sex*
  
  MaleFemale
- Patient's Race*
- Patient's Ethnicity*
- Patient's Religion
- If Pregnant, Due Date
  
  MonthDayYear
- Does the patient have an Advance Directive or living will?*
  
  YesNo
- Name of Emergency Contact*
  
  First NameLast Name
- Relationship to Patient*
  Partner, sibling, legal guardian, etc.
- Address same as Patient's*
  
  YesNo
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip CodeCountry
- Phone Number is same as Patient's*
  
  YesNo
- Phone Number
  
  Area CodePhone Number
- Insurance*
  
  Yes, the patient is covered by Medical Health InsuranceNo, the patient does NOT have insurance or is Self-PayCharity Care
- Upload Charity Care Letter
  
  Browse Files
  
  Cancelof
- Is the Patient the Primary Insurance Policy Holder?*
  
  YesNo
- Name of Primary Insurance Policy Holder *
  
  First NameLast Name
- Relationship to Patient*
- Is the Policy Holder's address the same as the Patient's?*
  
  YesNo
- Policy Holder's Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Policy Holder's DOB*
  
  MonthDayYear
- Phone Number is same as Patient's*
  
  YesNo
- Phone Number
  
  Area CodePhone Number
- Occupation
- Full-TimePart-TimeSelf-Employed
- Policy Holder's Employer
- Policy Holder's Employer Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Policy Holder's Employer Phone Number
  
  Area CodePhone Number
- Name of Insurance Co.*
- Address of Ins. Co.*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Phone Number of Ins.Co*
  
  Area CodePhone Number
- Insurance Policy #*
- Insurance Group #*
- Front Image of Insurance Card
  
  Browse Files
  If unable to upload, please email 4genetics@saintpetersuh.com Cancelof
- Back Image of Insurance Card
  
  Browse Files
  If unable to upload, please email 4genetics@saintpetersuh.com Cancelof
- Do you have Additional Insurance Coverage?*
  
  YesNo
- Insurance
  
  Yes, I am covered by additional Medical Health InsuranceOther
- Secondary Insurance Policy Holder Name
  
  First NameLast Name
- Relationship to Patient
- Is the Secondary Policy Holder's address the same as the Patient's?*
  
  YesNo
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  
  Area CodePhone Number
- DOB
  
  MonthDayYear
- Occupation
- Full-TimePart-TimeSelf-Employed
- Employer
- Employer Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Employer Phone Number
  
  Area CodePhone Number
- Name of Insurance Co.
- Address of Ins. Co.
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Phone Number of Ins. Co
  
  Area CodePhone Number
- Insurance Policy #
- Insurance Group #
- Front Image of Insurance Card
  
  Browse Files
  
  Cancelof
- Back Image of Insurance Card
  
  Browse Files
  
  Cancelof
- Do you have Additional Insurance Coverage?
  
  YesNo
- If the patient is a minor, please attach a legal form of photo identification of the authorized legal representative (e.g driver's license, passport)
  
  If unable to upload, please email a clear copy to 4genetics@saintpetersuh.com
- Patient/Authorized Legal Representative Photo Identification
  
  Browse Files
  
  Cancelof
- Signature*
- Time
  
  :HourMinutesAM/PM Option
- If the patient is a minor or otherwise unable to sign this Authorization, then the signature of the patient’s authorized legal representative must be recorded below:
- Name of Authorized Legal Representative
  
  First NameLast Name
- Authorized Legal Representative Signature
- Description of Authority
- Time
  
  :HourMinutesAM/PM Option
- Interpreter/ Translator Name
  
  First NameLast Name
- Time
  
  :HourMinutesAM/PM Option
- Enter the message as it is shown:*
- Should be Empty: