P.O Box 15118
1-800-436-4326
325 South Belmont Street
York, Pennsylvania 17405
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Patient Registration
Thank you for choosing Memorial Hospital. We want to make your experience here as convenient and efficient as possible. Our Pre-Registration Program allows the hospital to obtain all necessary registration and insurance information prior to your arrival.
You can take advantage of the Pre-Registration program in one of two ways. Please complete the secure on line registration form below or call us directly at 717-815-2351 Monday through Friday from 8 a.m. to 7:30 p.m. and Saturday from 8 a.m. to 12 p.m.
If you choose to register on-line please do so 48 hours before your expected arrival time. You will also need the following information with you before you begin.
*Your insurance card(s), including Medicare or Medicaid
*Your physician's written order form
*Your Social Security Number
*Your Employment Information
*Emergency Contact Information
*Primary Insurance Holders Date of Birth and Employer Information
Once we receive your Registration form, if additional information is needed you may be contacted by a Pre-Registration Specialist.
This online form is not for emergency visits. Anyone seeking emergency medical attention will be registered in our Emergency Department upon arrival.
General Information
Have you ever been a patient at Memorial Hospital?

Diagnosis/ICD-9 Code(s):
Reason for Visit:
Date:
Appointment Date:
Ordering Physician's Name:
Would you like to receive a copy of our HIPAA Privacy Policy?
Patient Information
Last Name:
First Name:
Middle Initial:
Previous or Maiden Name:
Date of Birth:
Address 1:
Address 2:
City:
State:
Zip:
Telephone 1:
Telephone 2:
Email Address:
Race:
Sex:
Marital Status:
Smoker:

Is the patient under 18 or does the patient have a court appointed guardian or guarantor?

Is the patient currently employed?

Comments:
Employment Information
Employer:
Address 1:
Address 2:
City:
State:
Zip:
Telephone:
Guardian/Guarantor Employment Information
Employer:
Address 1:
Address 2:
City:
State:
Zip:
Telephone:
Primary Insurance
Insured/Subsciber's Name:
Insured/Subscriber's Relationship to Patient:
Insured/Subscriber's Date of Birth:
Member ID/Policy Number:
Group Number:
Insurance Company Name/Carrier:
Insurance Company Address 1:
Insurance Company Address 2:
Insurance Company Member Servers Telephone Number:
Emergency Contact
Full Name:
Relation to Patient or Guardian:
Address 1:
Address 2:
City:
State:
Zip:
Home/Evening Phone Number:
Daytime Phone Number:
Comments: