St. Luke's Regional Medical Center

2720 Stone Park Blvd.
Sioux City, Iowa
51104

(712) 279-3500

Pre-Registration - Surgery and GI

Surgery and GI Pre-Registration - St. Luke's Health System, Sioux City, IA

Please view our Privacy Policy to learn about the secure electronic handling of your personal information.

Please contact your insurance company to verify coverage prior to having your surgery.

To ensure your registration has been completed upon your arrival at St. Luke?s, please pre-register at least two days prior to your expected date of service.

* required info
Surgery Information
Surgery Date: *
Surgery/Procedure:*
Surgeon: *
Family Physician *
Patient Information
Last Name: *
Legal First Name: *
Middle initial: *
Maiden Name:
Ethnicity: *
Gender: * Male
Female
Birthdate: *
Social Security Number:
Email Address:
Marital Status: *
Address:
Street: *
City: *
State: *
Zip: *
Home Phone: *
Alternate Phone:
Work Phone:
Employer: *
Employment Status (if applicable): Full-Time
Part-Time
Occupation: *
Spouse or Next-of-Kin Information
Name: *
Middle initial:
Birth Date: *
Relationship: *
Street Address: *
City: *
State: *
Zip: *
Employer: *
Home Phone: *
Alternate Phone:
Work Phone: *
Occupation: *
Alternate Emergency Contact Information
Name: *
Middle initial:
Birth Date: *
Relationship: *
Street Address: *
City: *
State: *
Zip: *
Employer: *
Home Phone: *
Alternate Phone:
Work Phone: *
Occupation: *
Insurance Information
Primary Insurance Company: *

None
Principal
HUMANA
Medicare
Medicaid (T19)
Blue Cross
(Wellmark, please specify Access, Out of State (what state), Select)

Blue Cross Sub-Type:
United Health Care
Coventry
Cigna
Aetna
Other
If other, please enter your Primary Insurance Company's name here.
Policy Number: *
Group Number: *
Employer Issuing Insurance:*
Name on Card: *
Insurance company phone number: *
Precertification or Prior Authorization Number:
Insurance company address:*
Secondary Insurance Company:
(If you enter a secondary insurance company, please fill out all the fields below)
Policy Number:
Group Number:
Employer Issuing Insurance:
Name on Card:
Secondary insurance company phone number:
Secondary insurance company address:
If this is a Blue Cross Blue Shield Insurance policy, in what state is it issued?
Medicare Secondary Payer Questions

Medicare requires that every patient seeking healthcare services fill out the following questionnaire regardless if you have filled it out in the past. Please complete the following questions, sign electronically and submit when you are done. Thank you for your cooperation.

Is patient service for PT OT or Speech Therapy and in a Home Health episode of care Yes
No
If so, has that Home Health agreed to pay for this care? Yes
No
Has patient transferred from a Skilled Nursing facility? Yes
No
If so, has that facility agreed to pay for this care? Yes
No
Does patient have Black Lung Medical Benefits? Yes
No
If yes, date benefits began:
Is patient in a government program such as Research Grant for this service? Yes
No
Has the Department of Veterans Affairs authorized and agreed to pay for care at Yes
No
Is patient service for Work related injury/illness? Yes
No
Is patient service for Auto related injury/illness? Yes
No
If yes, is it a 1 or 2 party accident? Yes
No
Is patient service for non-work/non-auto accident related injury/illness with liability? Yes
No
Is patient entitled to Medicare based on age? (If yes, questions A and B must be answered) Yes
No
A) Is patient employed and has insurance though employer? Yes
No
If no, patient date of retirement or explanation if retirement date not applicable. (open ended)
If yes, does employer have 20 plus employees? Yes
No
B) Is spouse employed and has insurance through employer for patient? Yes
No
If no, spouse date of retirement or explanation if retirement date not applicable. (open-ended)
If yes, does employer have 20 plus employees? Yes
No
Is patient entitled to Medicare based on disability? (If you answered yes, questions A and B must be answered) Yes
No
A) Is patient employed and has insurance though employer? Yes
No
If no patient date of retirement or explanation if retirement date not applicable. (open-ended)
If yes does employer have 100 plus employees? Yes
No
B) Is family member of the patient employed and has insurance through employer for patient? Yes
No
If no patient date of retirement or explanation if retirement date not applicabl
If yes does employer have 100 plus employees? Yes
No
Does patient have ESRD Medicare coverage? Yes
No
If yes, does patient have Employee Group Health plan coverage? (If yes, questions A-D must be answered) Yes
No
A) Has patient received a Kidney Transplant? Yes
No
If yes, date most recent dialysis began.(open-ended)
B) Has patient received Renal Dialysis for ESRD? Yes
No
If yes, date most recent dialysis began.(open-ended)
C) Has patient participated in a self-dialysis training program? Yes
No
If yes, date training started. (open-ended)
D) Is patient within the 30 month coordination period. Yes
No

Electronic Signature:
The information above is accurate and applicable to my hospitalization/hospital services covered under Medicare. (type name)

Other Information
Religious Preference:
Church Affiliation:

Pre-Admission