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Patient Pre-Registration

If you have a test or procedure scheduled at Mahaska Health Partnership, please fill out this form in its entirety. All fields marked with an asterisk(*) are required. If you have questions, call 641-672-3100. Online pre-registrations are checked M-F 7:00-4:30. Allow one business day for your registration to be processed.

Date of Visit(*)
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Appointment Time(*)
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Where will your visit/procedure take place?(*)
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Patient Information

First Name(*)
Please type your first name.

Last Name(*)
Please type your last name.

Middle Initial
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Other Name Used in Past (ie Maiden)
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Religion or Place of Worship
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Birthdate(*)
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Social Security Number(*)
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Address(*)
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City(*)
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State(*)
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Zip Code(*)
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Phone Number(*)
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Email(*)
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Best Time to Call(*)
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Marital Status
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Gender
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Race
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Employment Status
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Employer
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Employer Address
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Employer City
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Employer State
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Employer Zip Code
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Person Responsible For Bill

Is the patient responsible for the bill?(*)
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Name of Person Responsible(*)
Please type your first name.

Phone Number(*)
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Address(*)
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City(*)
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State(*)
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Zip Code(*)
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Birthdate(*)
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Patient's Relationship to Person Responsible(*)
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Employment Status
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Employer
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Employer Address(*)
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Social Security Number(*)
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Employer City(*)
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Employer State(*)
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Employer Zip Code(*)
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Illness / Injury Information

Is patient covered by Medicare?(*)
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Is this visit / procedure covered by workman's compensation?
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Is this illness or injury due to a non-work-related accident?
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Please explain below, include where, when and how this injury occurred:(*)
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Name of Liability Insurer
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Claim Number
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Insurer Phone Number
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Insurer Address
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Insurer City
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Insurer State
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Insurer Zip Code
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Is there any other information about this injury we should know?
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Insurance Information


Please bring your insurance card(s) with you to your appointment so that we can make a copy. If you do not have insurance, please click the Private Pay box below.

Private Pay
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Primary Insurance(*)
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Who is the policyholder?(*)
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Name of Policyholder(*)
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Policyholder Relationship to Patient(*)
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Policyholder Date of Birth(*)
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Policyholder Social Security Number(*)
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Insurance Company Address(*)
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Insurance Company City(*)
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Insurance Company State(*)
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Insurance Company Zip Code(*)
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Group / Employer Name
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ID/Policy/Subscriber Number(*)
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Group Number
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Secondary Insurance

Secondary Insurance
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Who is the policyholder?
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Name of Policyholder
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Policyholder Relationship to Patient
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Policyholder Date of Birth
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Policyholder Social Security Number
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Insurance Company Address
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Insurance Company City
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Insurance Company State
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Insurance Company Zip Code
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Group / Employer Name
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ID/Policy/Subscriber Number
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Group Number
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Provider Information

Referring Provider to be Seen

Ordering Provider
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First Name(*)
Please type your first name.

Last Name(*)
Please type your last name.

Address(*)
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City(*)
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State(*)
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Zip Code(*)
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Primary Care Provider

Primary Care Provider
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First Name(*)
Please type your first name.

Last Name(*)
Please type your last name.

Address(*)
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City(*)
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State(*)
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Zip Code(*)
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Emergency Contact Information

First Emergency Contact

Name(*)
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Relationship to Patient(*)
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Address(*)
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City(*)
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State(*)
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Zip Code(*)
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Second Emergency Contact

Name
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Relationship to Patient
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Address
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City
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State
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Zip Code
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Legal Information

Name of Medical Power of Attorney
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Phone Number of Medical Power of Attorney
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Do you have a living will?
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