Pre-Admission - ClipboardMD

Patient Pre-Admission

Math Captcha: 28 + 18 =

Patient Information

,

Is the Patient diabetic?

No Yes

Is the Patient the Responsible Party?

No Yes

Confirm Patient Information

Responsible Party Information

Responsible Party Information Detail

,

Emergency Contact

,

Procedure Details

ICD-10 Code

(alpha)

CPT Code

Left Right Bilateral N/A

(Must be obtained before surgery can be scheduled)

Auth/Ref Not Required

,

Type of Insurance

Medical / Health / Wellness Auto-related injury Work-related injury Non-covered / Self pay

Patient’s Relationship to Guarantor

Self Spouse Dependent

Responsible Party

,

Auto Related Injury Information

,

Worker’s Comp Information

,

Primary Insurance

Does [Guarantor] have another policy?

No Yes

Health Insurance Card Front

Health Insurance Card Back

,

Secondary Insurance

Health Insurance Card Front

Health Insurance Card Back

,

Primary Insurance

Secondary Insurance

,

Final Confirmation

Result

,

Please rate your experience

Surgery Center of Pottsville

Patient Pre-Admission

Patient Information

Confirm Patient Information

Responsible Party Information

Responsible Party Information Detail

Primary Insurance

Secondary Insurance