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Allen Medical Center
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Marcum and Wallace
Mercy Anderson
Mercy Clermont
Mercy Fairfield
Mercy Health Perrysburg
Mercy Hospital of Defiance
Mercy Hospital Tiffin
Mercy Hospital Willard
Mercy Memorial/Urbana
Mercy West Hospital
Springfield Regional Medical Center
St Anne Mercy Hospital
St Charles Mercy Hospital
St Elizabeth Boardman
St Elizabeth Health Center
St Joseph Health Center
St Rita's Medical Center
St Vincent Mercy Med Center
The Jewish Hospital - Mercy Health
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Many insurance companies require a pre-certification or a physician referral prior to services being rendered. Please check with your insurance company to ensure that appropriate authorization has been obtained.

Please complete and submit the pre-registration form below. Prior to submitting the completed form, you will have the opportunity to review and edit any information entered into the pre-registration form.

Thank you for choosing Mercy Health for your services.
 
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Patient Information 
* First Name: 
Middle Initial: 
* Last Name: 
* Address: 
* City: 
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* Zip: 
* Phone Number:    -
* Best time to call to complete your registration:  :
E-mail Address: 
* Last 4 of Social Security Number: 
* Date of Birth: 
* Gender: 
* Race/Ethnicity: 
* Marital Status: 
Religious Preference: 
Church Attending: 
 
Emergency Contact 
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* Relationship: 
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Patient Employer Information 
* Is the patient currently employed?    
* Occupation: 
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* Current Status: 
* Retirement Date:
 
    
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Responsible Party (Person responsible for the bill) 
* Is the responsible party the same as patient?   
* Responsible Party Name: 
* Address: 
* City: 
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* Phone Number:    -
E-mail Address: 
* Last 4 of Social Security Number: 
* Date of Birth: 
* Relationship to Patient: 
 
     
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Responsible Party Employer Information 
* Is the responsible party's employer the same as patient?   
* Is this person currently employed?   
* Occupation: 
* Employer Name: 
* Address: 
* City: 
* State: 
* Zip: 
* Phone:    -
* Current Employment Status: 
* Retirement Date:
 
     
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Registration Record 
* Date of Admission/Testing: 
* Is your service related to an injury? 
* Please provide the date of the injury: 
* What type of injury did you incur? 
* What type of procedure or test do you need? 
* Do you have insurance? 
* Insurance Name:
* Subscriber ID:
* Group Number:
* Do you have secondary insurance? 
* Payor Name:
* Subscriber ID:
* Group Number:
* Is the reason for your visit related to an auto accident? 
* Is the reason for your visit due to a work related injury? 
* Are you a Medicare patient? 
* Is the illness/injury due to an automobile accident, liability accident or Workman's Compensation?  
* Is illness covered by the Black Lung Program, Veterans Administration or research program?  
* If under 65, are you a renal dialysis patient in your first 30 months of Medicare entitlement?  
* Is patient covered by a large group health plan through either the patient's employer or Yes No spouse's current employer and the plan is primary over Medicare?  
* Medicare Beneficiary's (Patient) Retirement Date  
* Is the patient entitled to Medicare based on Disability?