Fairview Pre-Registration Form

FAIRVIEW HEALTH SERVICES WEB PRE-REGISTRATION FORM

Welcome to Fairview Health Services Secured On-Line Preregistration form. Please do not complete this form if your visit is just for a physician clinic visit. You may also call 612-672-2000 for any questions pertaining to this form. In order to complete the online form, please have the following information available:

Your date of service
The name of the site that you are having services.
The name of your physician performing the procedure, the name of your primary care physician and the name of your referring physician.
Demographic information such as address and phone numbers (home, work and cell phone).
Next of kin information (name and phone number)
Employer information (name, address, and phone number)
Insurance information and/or billing information. (please have all insurance cards and/or billing information readily accesible).
If you need help, click on the ? at the top of each section for definitions you may find helpful while filling out your form. For assistance, please call 612-672-2000.


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Please note:

To protect the data you are entering, your internet session will automatically timeout after one hour of no activity. Please take the time to gather all required information beforehand to avoid re-entry.

Thank You.

Visit Information

*Facility

*Date of visit

*Reason for visit

*Is this visit due to an accident or work related injury?

Yes No

*Would you like to be listed in the patient directory on the date of your procedure?

Yes No

(If Yes, your name, location in the hospital, phone number, if you are an inpatient and general condition will be provided if callers ask to speak to you. If No, they will be told you are not a patient at this facility.)

?	Physician Information

		Admitting Physician
*Last Name
*First Name

		Primary Care
*Last Name
*First Name
*Primary Clinic

		Referring Physician
Last Name
First Name
Clinic Name