WC Registration Form 2022

Baylor Scott & White Medical Center Frisco
5601 Warren Parkway
Frisco, TX 75034

Women's Center Registration Form

Completion of this form allows us to register you & file with your insurance.

NOTE: * Denotes Required Field.

Registration Type: *

Women Center Registration (Labor and Delivery)

Please select your obstetrician from the list: *

If you do not see your obstetrician listed, they do not have privileges at this facility.

Patient Information:

Patients Name: *

First Name Last Name

Patients Date of Birth: *

Month Day Year

Gender: *

Male Female

Patients Address: *

Street Address:

Apt. # (if applicable)

City State

Zip Code Country

Patients Phone #: *

Area Code Phone Number

Patients E-mail: *

Patients Marital Status:

Married Single Divorced

Social Security #: *

Race: *

Religion:

Are you of hispanic origin: *

Yes No

Primary Family Physician: *

Family Physician Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Family Physician Phone #:

Area Code Phone Number

Patients Employer Name: *

Patients Employer Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Patients Employer Phone #: *

Area Code Phone Number

Patients Occupation:

Employee Status:

Full-Time Part-Time Unemployed Retired Active Military Duty Student Unknown

Next of Kin:

Name: *

Address (if different then Patient):

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone #: *

Area Code Phone Number

Relationship to Patient: *

Person to Notify:

Same as Next of Kin (If no, please fill out below): *

Yes No

Name:

Address (if different then Patient):

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone #:

Area Code Phone Number

Relationship to Patient:

Guarantor Section:

Is patient a minor (If no, skip guarantor section): *

Yes No

Guarantor Name:

First Name Last Name

Guarantor Date of Birth:

Month Day Year

Guarantor Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Guarantor Phone Number:

Area Code Phone Number

Guarantor Email:

example@example.com

Guarantor Social Security #:

Relationship to Patient:

Guarantor Employer Name:

Guarantor Employer Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Guarantor Phone Number:

Area Code Phone Number

Guarantor Occupation:

Guarantor Employee Status:

Full-Time Part-Time Unemployed Retired Active Military Duty Student Unknown

Insurance Provider Information:

Insurance Provider: *

ID #: *

Group #: *

Policy Holder Name: *

First Name Last Name

Policy Holder Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Policy Holder Date of Birth: *

Month Day Year

Policy Holder Social Security #:

Policy Holder Relationship to Patient: *

Policy Holder Employer Name:

Policy Holder Employer Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Secondary Insurance Provider Information:

Do you have a secondary insurance (If no, please skip): *

Yes No

Insurance Provider:

ID #:

Group #:

Policy Holder Name:

First Name Last Name

Policy Holder Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Policy Holder Date of Birth:

Month Day Year

Policy Holder Social Security #:

Policy Holder Relationship to Patient:

Policy Holder Employer:

Policy Holder Employer Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Do you have any sensory or physical impairments (If yes, please explain below): *

Yes No

Physical Impairments:

Recognize that text message communication is not a completely secure method of communication, do you consent to receiving text messages regarding your account? *

Yes No

Baby Insurance Provider Information:

Whose Insurance plan will the baby be covered under: *

Mother Father

Insurance Provider: *

ID #:

Group #:

Policy Holder Name:

First Name Last Name

Policy Holder Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Policy Holder DOB:

Month Day Year

Policy Holder Social Security #:

Policy Holder Relationship to Patient:

Patient Information Continue:

Date of Patients Last Menstrual Period:

Month Day Year

Expected Delivery Type: *

Vaginal C-Section

Obstetrician's Name: *

Do you have any Advance Directive documents (If yes, please select all that apply):

Advance Directive Medical Power of Attorney Living Will DNR Mental Health Directive

Expected Date of Delivery: *

Month Day Year

Would you like to enroll in CommonWell Health Information Exchange? *

Yes No

If yes, please enter your Drivers License Number:

Location of These Documents: