Maternity Pre-Registration Form

NOTE: required information is marked with a red asterisk (*) as well as a light yellow background.
 

Expectant Mother's Information
Patient's first name: *
 Patient's middle name:
 Patient's last name: *
Patient's maiden/birth name: *
 Date of Birth: *
 Social Security #:
 Last Menstrual Period Date:
 Due date: *
Is the patient diabetic?
Primary phone number: *
 Patient email address:
 Veteran Status:
Race: *
 Religious Preference:
 Language:
 Marital Status: *
Place of birth:
Does patient have a proxy?
Mailing address: *
 City: *
State: *
 ZIP code: *

 

Healthcare Proxy Information
Proxy first name:
 Proxy last name:
Proxy relationship to patient:
Proxy phone number:
Mailing address:
City:
State:
ZIP code:

 

Employment Information
Patient is employed. Patient is unemployed. Patient is a minor. Patient is retired.
Employer name:
Occupation:
If retired, date of retirement:
 Employer phone number:
Mailing address:
City:
State:
ZIP code:

 

Emergency Contact Information
Emergency contact first name:
 Emergency contact last name:
Relationship to patient:
Primary phone number:
 Alternate phone number:
Mailing address:
City:
State:
ZIP code:

 

Additional Medical Information
Has the patient been admitted to a hospital or nursing care facility in the last 12 months?
Yes No
Name of facility that admitted patient:
 Admission date:
 Discharge date:
Primary Care Physician:
 Obstetrician: *
 Pediatrician:
Patient's Primary Pharmacy:
 Primary Pharmacy Location:
 Patient's Primary Pharmacy Insurance:
Does the patient have insurance?
 Is the baby covered by Medicaid? *

 

Insurance Information (Primary)
Insurance Name:
 ID Number:
 Group Number:
Subscriber:
 Subscriber Date of Birth:
 Employer:
Relationship to Patient:
 Insurance phone number:

 

Insurance Information (Secondary)
Insurance Name:
 ID Number:
 Group Number:
Subscriber:
 Subscriber Date of Birth:
 Employer:
Relationship to Patient:
 Insurance phone number:

 

Insurance Information (Baby)
Insurance Name: *
 ID Number: *
 Group Number: *
Subscriber: *
 Subscriber Date of Birth: *
 Employer: *
Unborn Medicaid #:
Relationship to Patient: *
 Insurance phone number: *

 

Guarantor Information (responsible for payment)
First Name:
 Middle Name:
 Last Name:
Relationship to Patient:
 Phone number:
Date of Birth:
 Social Security #:
Mailing address:
City:
State:
ZIP code:
Employer name:
Employer Phone Number:
Occupation:
If retired, date of retirement:
Employer Mailing address:
Employer City:
Employer State:
Employer ZIP code:
Approximate number of employees:
1-19 20-99 Over 100

 

Expectant Father or Second Parent's Information
Parent's first name:
 Parent's middle name:
 Parent's last name:
Sex:
 Date of Birth:
 Social Security #:
 Marital Status:
 Primary phone number:
Mailing address:
City:
State:
ZIP code:
Employer name:
Occupation:
Employer Mailing address:
Employer City:
Employer State:
Employer ZIP code:
  Employer Phone Number:

 

Newborns & health insurance:

For information about how your newborn will be financially covered for your stay, please click the button below and review to confirm that the proper steps have been taken to ensure that your account is financially secured.
Click here to view.


Empire Blue Cross Blue Shield Form (BCBS):

If you have the Empire Plan, please complete this authorization form and fax it to 315-470-7014, or bring to the Crouse Admitting Office during your visit.
Click here for the Form

Enrollment assistance:

Crouse Hospital, in an effort to provide the best in patient care and satisfaction, offers assistance with enrollment into health benefit plans. Many uninsured parents and other adults may be eligible for NY State Health Insurance Programs. This free service is provided by Marketplace Facilitated Enrollers from local healthcare companies in collaboration with Crouse Health. To have a Facilitator assist you with enrollment please check the second box below.