Women's Health Specialists Registration

Thank you for choosing Women's Health Specialists for your healthcare needs.

Women's Health Specialists at St. Anthony North Hospital
8510 Bryant Street, Suite 320
Westminster
303-426-2580

Please remember that to effectively process your registration we must receive it at least 48 hours prior to your appointment, if you have less than 48 hrs before the time of your procedure you can register in the office or by printing the forms and then bringing them with you to your appointment.

A note about our data security and your privacy:

The security of your personal and health information is paramount to us at Women's Health Specialists and St. Anthony Hospitals. Our data encryption ensures that the information you submit here is protected and secure. The pre-registration form you complete is housed on a secure server assuring that your information is protected and that our process meets HIPAA  (Health Insurance Portability & Accountability Act of 1996) guidelines. 

Your information will be used solely for the purpose of pre-registration and your medical record. Women's Health Specialists and St. Anthony Hospitals does not share information with any outside organizations other than that shared with your insurance company to process your claim. Our secure server protects your personal and health information.

Pre-registration Form

How did you hear about our practice?
*
Patient Information:
* First Name:
* Middle Initial:
* Last Name:
Prefer to be called:
* Date of Birth:
* Social Security Number:
Marital Status:	Please choose one: Single Married Divorced Separated Widowed
Race:	Please choose one: Caucasian African American Asian Native American Latino Other
Religion:
* Address:
* City:
County:
* State:
* Zip:
* Home Phone:
Work Phone:
Cell Phone:
Email:
* Primary Care Physician:
Physician's Phone:
Employer:
Occupation:
Insurance Information (Primary):
* Insurance Company:
* Member ID:
* Street Address:
City:
State:
Zip:
Effective Date:
Copay:
Group Number:
* Policy Holder Name:
* SSN of Policy Holder:
Policy Holder Date of Birth:
Relation to Patient:
Sex:	Choose one: Male Female
Relationship to Patient:
* Employer Name:
Occupation:
Secondary Insurance Information:
Insurance Company:
Member ID:
Claims Address:
City:
State:
Zip:
Effective Date:
Group:
Policy Holder Name:
SSN of Policy Holder:
Policy Holder Date of Birth:
Relationship to Patient:
Sex:	Choose one: Male Female
Policy Holder Employer:
Policy Holder Occupation:
Guarantor Information (Person responsible to pay bill)
Guarantor Name:
Date of Birth:
Guarantor SSN:
Relationship to Patient:
Guarantor Employer Name:
Guarantor Occupation:
Emergency Contact (Spouse or Next of Kin)
* Emergency Contact Name:
Relationship to Patient:
Home Phone:
Work Phone:
By typing my name below I am certifying that I have read the statements below and agree to them.
Deductibles, co-payments, or co-insurance and payments for non-covered services are required at the time of service. Our office will only file a claim with an insurance company with whom we have a contract.
I understand that accounts more than 90 days past due may be turned over to collections and any legal fees or costs will be my responsibility.
I authorize my insurance benefits to be paid directly to the treating physician, realizing I am responsible to pay the remaining balance for services.
* Name of Patient or Authorized Representative:
* Date of Form Completion:
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* Required Fields