• Tobacco-Free Statement
• Patient Rights, Responsibilities, Grievances
• Patient Pre-Registration
• Personal Health Record
• Medical Records
• Gift Shops & Boutiques
• Medical Financial Assistance Program
• Personalized Search Request
• Arizona Advance Directives Registry
• Living Will
• Visitor Resources
• Interpretation and Translation Services
• Ask the Expert Articles
• Online Bill Pay

Patient Pre-Registration

Welcome to the Scottsdale Healthcare online patient pre-registration form. Use this form to save time by submitting your pre-registration information prior to your admittance. Please do not use this form to submit pre-registration information for a normal doctor's visit.

All fields in bold indicate information necessary for on-line pre-registration. If you do not have all of the information indicated in bold, do not proceed. The system will not accept your registration. To complete your pre-registration in a timely fashion, Scottsdale Healthcare must obtain a copy of both the front and back sides of your insurance card. Please note your full name and date of admission on the copy and fax it to the appropriate facility:

Attention: Pre-Registration Coordinator

Scottsdale Healthcare recognizes the confidential nature of the information you are about to submit. For this reason, you are now working in a new secured window. Your browser will indicate this by displaying a padlock in the bottom right corner of your browser window. You can feel secure knowing that the information you are providing will be kept in strict confidence and exceeds the Internet standards necessary for transmitting this type of information. Once you have submitted your pre-registration form you will receive an e-mail confirmation and confirmation number. Keep this number for your records. Thank you for choosing Scottsdale Healthcare.

Below is you Pre-Registration confirmation number. Please write this number down and keep it for your records.

Patient's Details

Reason for Visit

NoneGreenbaum Surgery Center Greenbaum Pain Center Osborn Maternity Services Osborn Medical Services Osborn Surgical Services Piper Surgery Center Shea Maternity Services Shea Medical Services Shea Pediatric Services Shea Surgical Services - Adult Shea Surgical Services - Pediatric Shea Pain Center Shea Diabetes Management Shea VGP Cancer Center Sleep Disorders Center Thompson Peak Medical Services Thompson Peak Radiology Services Thompson Peak Surgical Services

Personal Details

Last Name

Home Phone

First Name

M.I.

Cell Phone

SSN

Address

Gender

Male

Female

Date of Birth

City

Place of Birth

State

ArizonaAlabama Alaska American Samoa Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming

Religion

Zip

Language

Country

United States of AmericaMexico Canada

Race

CaucasianHispanic Native American African American Middle Eastern

Email

Marital Status

NoneDivorced Married Separated Single Significant Other Widowed

Parent/Guardian (required if patient is under 18 years old):

Last Name

First Name

Procedure Details

Ordering Physician

Last Name

Procedure

First Name

Admission Date

Employer Details

Employer

City

Work Phone

State

ArizonaAlabama Alaska American Samoa Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming

Address

Zip

Retire Date

Spouse/Nearest Relative

Last Name

If the information below is the same as the patient's details, just check this box.

First Name

Home Phone

Date of Birth

Address

Relationship

Employer

City

Work Phone

State

ArizonaAlabama Alaska American Samoa Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming

Zip

Insurance Information

The following information can be found on your insurance card. If you do not have insurance, please answer "none", "n/a", or "not applicable" in all required insurance fields.

Primary Insurance

Insurance Name

Who is the primary insurance holder?

Are you on an Obstetrics Self-Pay Package Plan?

Yes

No

Patient

Relative

None

Phone

Insured's Details

Address

Insured's Name

SSN

City

Address

State

ArizonaAlabama Alaska American Samoa Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming

Zip

City

Policy#

State

ArizonaAlabama Alaska American Samoa Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming

Group#

Zip

Facility Authorization#

Date of Birth

Primary Care Physician

Phone

Last Name

First Name

Insured's Employer Details

Employer Name

Phone

Address

City

State

ArizonaAlabama Alaska American Samoa Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming

Zip

Secondary Insurance

Insurance Name

Who is the primary insurance holder?

Phone

Patient

Relative

Neither

Address

Insured's Details

Insured's Name

City

SSN

State

ArizonaAlabama Alaska American Samoa Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming

Address

Zip

Policy#

City

Group#

State

ArizonaAlabama Alaska American Samoa Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming

Facilitation Authorization#

Zip

Primary Care Physician

Date of Birth

Last Name

Phone

First Name

Insured's Employer Details

Employer Name

Phone

Address

City

State

ArizonaAlabama Alaska American Samoa Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming

Zip

Submit