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Awards & Accolades

Healthcare Equality Index 2013
America's Best Hospitals 2014-15

America's Best Hospitals 2014-15

U.S. News and World Report

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Best Doctors 2013
 
 

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Patient Pre-Registration

Please submit this online information at least four business days prior to your scheduled visit, or six weeks prior to your expected delivery date. This allows us adequate time to verify and pre-certify your insurance (if applicable).

Also available, if you prefer, is pre-registration by phone. If you are scheduled for a surgical/medical procedure please call 718.925.6995 Monday through Friday between the hours of 8:00a.m. to 6:00 p.m. and we will be glad to assist you. Maternity patients please call 212.434.3198. Your questions are welcome.

If your procedure/service is within 72 hours of today, please do not use this online form. Please call our pre-registration department at the numbers provided above.

Maternity patients may also download the Pre-Registration Form (PDF) and fax it to 212.434.3424.

Fields marked with a * indicate a required field.



Registration Details

Are you pre-registering for Maternity?:
Anticipated Due Date*:
 
Date of Admission*:
 
Date of Surgery*:
 
Location*:
Physician's Name*:
Primary Care Physician's Name*:

Patient Information

Patient's Name*:
Please provide patient's name as it appears on legal documents.
Address1*:
Address2:
City*:
State*:
Zip*:
County Of Residence*:
Phone*:
Cell/Additional Phone Number:
Email Address*:
Verify Email Address*:
Social Security Number:  
Race*:
Ethnicity*:
Sex*:
Marital Status*:
Date of Birth*:
 
Mother's First Name:
Father's First Name:
Mother's Maiden Name:
Patient's Maiden Name:
Place of Birth:
Are you an Employee of LHH?*:
Religion:
Preferred Language:
Do You Carry An Organ Donors
Card?*:
Occupation:
Employer:
Employer Address1:
Employer Address2:
Employer City:
Employer State:
Employer Zip:
Length of Service With Current Employer:
Years
Months
Employer’s Phone: Ext
Employment Status*:

Advance Directives

Advance Directives*:
Type*:

Accident Information

If this admission is the result of an accident, please complete this section in full.

Type of Accident:
Time of Accident:
 
Date of Accident:
 
Location of Accident:
Address1:
Address2:
City:
State:
Zip:

Person Responsible For Financial Arrangements

Name of Primary Insurance Policy Holder*:
Relation to Patient*:
Name*:
Address1*:
Address2:
City*:
State*:
Zip*:
County Of Residence*:
Phone*:
Social Security Number:  
 Employment Status*:
Sex*:
Date of Birth*:
 
Occupation*:
Employer*:
Employer Address1*:
Employer Address2:
Employer City*:
Employer State*:
Employer Zip*:
Phone: Ext

Person to Contact in an Emergency

Relation to Patient*:
Name*:
Address1*:
Address2:
City*:
State*:
Zip*:
Home Phone*:
Work Phone*: Ext

Legal Next of Kin

If patient is 18 or under (25 if student) enter other parent information below.
If patient is married enter spouse information. otherwise enter closest relative.

Relation to Patient:
Name:
Date of Birth:
 
Address1:
Address2:
City:
State:
Zip:
Home Phone:
Work Phone: Ext

Miscellaneous

Have you ever been a patient at Lenox Hill Hospital?*:
Have you been an inpatient in a Hospital or Skilled Nursing Facility within the last 60 days?*:
SELF PAY / UNINSURED

Insurance Information

Please select your type(s) of insurance and complete the appropriate sections below for both patient and spouse, or both parents if patient is 21 or under . . . and attach a copy of both sides of the insurance.


Medicare

Name of Beneficiary:
Claim Number:
Is Entitled To: Hospital (Part A):
Hospital (Part B):
Sex:
Effective Date:
 
Are you retired?:
Is your spouse retired?:
Do you have other insurance?:
Date of retirement - Patient:
 
Date of retirement - Spouse:
 

Empire Blue Cross

Subscriber's Name:
 Prefix:  
 Identification:  
 Suffix:  

Other Blue Cross

Blue Cross/Blue Shield of:
Subscriber's Name:
Identification:
 
Group Number:
 

Other Insurance - (HMO, Union, Travelers,Metropolitan, etc.)

Name on Card:
Policy ID Number:
Policy Group Number:
 Payor ID Number:
 Group Name:
Employer Name: As it appears on the card.
Address1:
Address2:
City:
State:
Zip:
Phone:
Insurance Company Name:
Address1:
Address2:
City:
State:
Zip:
Phone:

Workers Comp

Insurance Company Name:
Address1:
Address2:
City:
State:
Zip:
Phone:
Employer Name:
Employer Address1:
Employer Address2:
Employer City:
Employer State:
Employer Zip:
Employer Phone : Ext
WCB Number:
Accident Date:
 
Accident Time:
 
Claim Filed:

No Fault

Insurance Company Name:
Address1:
Address2:
City:
State:
Zip:
Phone:
Car Owner's Name:
Address1:
Address2:
City:
State:
Zip:
Phone:
Insurance Agent Or Attorney Name:
Phone:
Accident Date:
 
Accident Time:
 
Policy Number:
 File No:  

Medicaid

Name on Card:
ID Number:
 
ISO Number:
 
Access Number:
 
Seq Number:
 
 
Comments:

If you elect to electronically submit a completed Pre-registration Form or any other information to Lenox Hill 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 Lenox Hill 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 Lenox Hill Hospital by you through this web site, including a completed Pre-registration Form, does not create or constitute any relationship between you and Lenox Hill Hospital, its affiliates, or any of the physicians on its staff, to which any privilege may attach.