Pre-Registration

GMH Online Pre-Registration Form
117 Hospital Drive
Petersburg, WV 26847

Use this form to pre-register for your test, procedure, surgery, or delivery.

If you have services scheduled at Grant Memorial Hospital (GMH), please fill out the following form in it’s entirety. If you have any questions about the online pre-registration process or would like to pre-register by telephone, please call GMH Pre-Registration Department at (304) 257-1026 x2250.

PLEASE NOTE: Online pre-registrations are checked Monday – Friday from 7:30am – 8:00pm. Please allow at least one business day before your appointment for your pre-registration form to be processed. If there is less than one business day before your appointment, please register by calling the pre-registration department at (304) 257-1026 x2250.

Before you begin the pre-registration form, you are encouraged to review GMH’s “Notice of Privacy Practices.” To review that information, please click here.

Pre-Registration StartStep 1 of 6

Is the patient the guarantor? *

The guarantor is the person who is guaranteeing payment (usually the same as the patient if the patient is over age 18).

Do you carry Insurance or are you self-pay? *

Yes
No
Self-Pay

Do you have secondary Insurance?

Do you have a third insurance?

Are you insured by Medicare?

What is the date of your appointment? *

What service are you pre-registering for? *

*If your service is not listed, please contact pre-registration at (304) 257-1026 x2250.

Terms and Conditions *Do you agree to our Terms and Conditions?

If you elect to electronically submit a completed Pre-registration Form or any other information to Grant Memorial Hospital through this web site, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Grant Memorial Hospital and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of any information submitted electronically by you through this web site and from any errors or omissions in the data you provide. Additionally, the provision of any information to Grant Memorial Hospital by you through this web site, including a completed Pre-registration Form, does not create or constitute any relationship between you and Grant Memorial Hospital, its affiliates, or any of the physicians on its staff, to which any privilege may attach.

Last Name *

First Name *

Middle Initial

Birthdate *

Race *

Sex *

Ethnicity *

Marital Status *

Street Address *

City *

State *

Zip *

Phone *

Email *

Guarantor Information

Last Name *

First Name *

Middle Initial

Relationship to Patient *

Address *

City *

State *

Zip *

Phone *

Physician Information

Admitting / Ordering Physician *

Family Physician *

Employer's Name

Employer's Street Address

Employer's City

Employer's State

Employer's Zip Code

Employer's Phone Number

Emergency Contact #1

Last Name *

First Name *

MIddle Initial

Phone Number *

Work Phone Number

Relationship to Patient *

Street Address *

City *

State *

Zip *

Emergency Contact #2

Last Name

First Name

Middle Initial

Phone Number

Work Number

Relationship to Patient

Street Address

City

State

Zip Code

Primary Insurance

Insurance name

Insured's Date of Birth

Insured's Name

Insured's Sex

Relationship to Patient

Policy Number

Group Name

Group Number

Secondary Insurance

Insurance Name

Insured's Date of Birth

Insured's Name

Insured's Sex

Relationship to Patient

Policy Number

Group Name

Group Number

Third Insurance

Insurance Name

Insured's Date of Birth

Insured's Name

Insured's Sex

Relationship to Patient

Policy Number

Group Name

Group Number

You are not required to fill this section out, please submit the form.

Medicare Questions

PART I

Are you receiving Black Lung (BL) Benefits?

What date did the benefits begin?

Are the services to be paid by a government program such as a research grant?

Has the Department of Veterans Affairs (DVA) authorized and agreed to pay for care at this facility?

Was the illness/injury due to a work related accident/condition?

Date of Injury / Illness

Name of Workers Comp Plan

Address of Workers Comp Plan

Policy or Identification Number

Name of Employer

Employer's Address

Employer's City

Employer's State

Employer's Zip

Part II

Was the illness / injury due to a non-work related accident?

Date of Accident

What type of accident caused the illness/injury?

Name of no-fault or liability insurer:

Address of no-fault or liability insurer:

City, State, and Zip Code of no-fault or liability insurer:

Insurance Claim Number

Was another party responsible for this accident?

Name of any liability insurer:

Address of any liability insurer:

City, State, Zip Code of any liability insurer:

Insurance Claim Number:

Part III

Are you entitled to Medicare based on?

Part IV - Age

Are you currently employed?

Yes
No
Never Employed

Date of Retirement?

Name of Employer

Address of Employer

City, State, and Zip Code of Employer

Is your spouse currently employed?

Yes
No
Never Employed

Date of Spouse's Retirement

Name of Spouse's Employer

Address of Spouse's Employer

City, State, and Zip Code of Spouse's Employer

Do you have a Group Health Plan(GHP) coverage based on your own, or a spouse's current employement?

Does the employer that sponsors your GHP employ 20 or more employees?

Name of GHP

Address of GHP

City, State, and Zip Code of GHP

Policy Identification Number

(this number is sometimes referred to as the health insurance benefit package number)

Group Identification Number

Membership Number

(prior to the Health Insurance Portability and Accountability Act (HIPAA), this number was frequently the individual's Social Security Number (SSN); it is the unique identifier assigned to the policyholder/patient)

Name of Policyholder/Named Insured

Relationship to Patient

Part V - Disability

Are you currently employed?

Yes
No
Never Employed

Date of Retirement

Name of Employer

Address of Employer

City, State and Zip Code of Employer

If married, is your spouse currently employed?

Yes
No
Not Employed
Not Married

Date of Spouse's Retirement

Name of Spouse's Employer

Address of Spouse's Employer

City, State, and Zip Code of Spouse's Employer

Do you have a Group Health Plan coverage based on your own, or a family member's current employment?

Are you covered under the Group Health Plan of a family member other than your spouse?

Name of your family member's employer

Address of your family member's employer

City, State, and Zip Code of your family member's employer

Does the employer that sponsors the GHP employ 100 or more employees?

Name of Group Health Plan

Address of Group Health Plan

City, State, and Zip Code of GHP

Policy Identification Number

(this number is sometimes referred to as the health insurance benefit package number)

Group Identification Number

Membership Number

Name of Policyholder/Named Insured

Relationship to Patient

PART VI - ESRD

Do you have a Group Health Plan (GHP) coverage?

Name of GHP

Address of GHP

City, State, and Zip Code of GHP

Policy Identification Number

(this number is sometimes referred to as the health insurance benefit package number)

Group Identification Number

Membership Number

Name of Policyholder/Named Insured

Relationship to Patient

Name of employer, if any, from which you receive GPH coverage

Address of employer, if any, from which you receive GHP coverage

Have you received a kidney transplant?

Date of Transplant

Have you received maintenance dialysis treatments?

Date Dialysis Began

If you participated in a self-dialysis training program, provide date training started:

Are you within the 30-month coordination period?

(The 30-month coordination period starts the first day of the month an individual is eligible for Medicare (even if not yet enrolled in Medicare) because of kidney failure (usually the fourth month of dialysis. If the individual is participating in a self-dialysis training program or has a kidney transplant during the 3-month waiting period, the 20-month coordination period starts with the first day of the month of dialysis or kidney transplant.)

Are you entitled to Medicare on the basis of either ESRD and age or ESRD and disability?

Was your initial entitlement to Medicare including simultaneous or dual entitlement based on ESRD?

Does the working age or disability MSP provision apply?

Is the GHP primarily based on age or disability entitlement?