Yuma Regional Medical Center
 

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Congratulations on your upcoming delivery! It's recommended you pre-register for your hospital stay by completing the maternity pre-admission form below a couple of months prior to your due date.

If you have already registered in person at the hospital, please do not complete the electronic pre-registration.

After the information submitted through the electronic pre-registration form has been processed, you will receive a phone call from YRMC's Patient Access department with a confirmation number.

When you are ready to deliver and arrive at the hospital, a registrar will confirm the registration information with you. You will also be asked to sign a consent form upon arrival. Please remember to bring to the hospital:

  • Identification (such as driver's license)
  • Insurance cards
  • Co-pay (if applicable)

Note: A deposit is required for self-pay patients, or if you are insured but your procedure is not covered by your plan. Please contact the YRMC Patient Access department at 928-336-7614 before your expected date of arrival.

Preserving the confidentiality of your personal information is important to YRMC. This e-registration form is secure, and the personal information you send through it will be kept confidential by YRMC's encryption technology. 



* Indicates required information
Expected Date of Delivery:  Calendar (mm/dd/yyyy)
OB Physician's Name (Last, First): * 
Primary Care Physician: 
Patient's Last Name: * 
Patient's First Name: * 
Patient's Middle Initial: 
Social Security Number: 
Click if No SS: 
Date of Birth: *  Calendar (mm/dd/yyyy)
Mother's Maiden Name: 
Patient's Physical address: 
City: 
State: 
Zip Code: 
Country: 

If Other, please specify:

Patient's Mailing Address: * 
City: * 
State: * 
Zip Code: * 
Country: * 

If Other, please specify:

Home Phone: * 
Cell Phone: 
Email Address: 
Religion (Optional): 

If Other, please specify:

Ethnicity List: 

If Other, please specify:

Race List: 

If Other, please specify:

Marital Status: 

If Other, please specify:

Primary Language: * 
Need Interpreter: 

Have you received care or treatment at YRMC: * 

Employment Status: * 
Employer Name: 
Employer Address: 
City: 
State: 
Zip Code: 
Country: 

If Other, please specify:

Employer Phone Number: 
1.- Emergency Contact Name: * 
Relationship to Patient:  * 
Address: * 
Phone Number: * 
2.- Emergency Contact Name:  
Relationship to Patient: 

If Other, please specify:

Address: 
Phone Number: 
Check if Selfpay: 
1.- Primary Insurance Name: * 
Policy Number: * 
Group Number: 
Insurance Phone Number: * 
Insurance Mailing Address: 
City: 
State: 
Zip Code: 
Subscriber Last Name: * 
Subscriber First Name: * 
Subscriber Middle Initial: 
Subscriber Date of Birth: *  Calendar (mm/dd/yyyy)
Subscriber Gender: 
Subscriber's Employer:  
Subscriber's Employment Status: 
Subscriber's Employer Address: 
City: 
State: 
Zip Code: 
Country: 

If Other, please specify:

Employer's Phone Number: 
2.- Secondary Insurance Name: 
Policy Number: 
Group Number:  
Insurance Phone Number:  
Insurance Mailing Address: 
City: 
State: 
Zip Code: 
Country: 

If Other, please specify:

Subscriber Last Name: 
Subscriber First Name: 
Subscriber Middle Initial: 
Subscriber Date of Birth:  Calendar (mm/dd/yyyy)
Subscriber Gender: 
Subscriber's Employer: 
Subscriber's Employment Status: 
Subscriber's Employer Address: 
City: 
State: 
Zip Code: 
Country: 

If Other, please specify:

Employer's Phone Number: 
Do you have and Advance Directive, such as a Living Will or Durable Power of Attorney for Health Care? ***if yes, please bring a copy at the time of your admission*** * 
Do yo need special accommodations, such as Translation, Visual Aid, etc.? ***If yes, please specify so that prior arrangements can be made for the day of your visit. *** * 
Special Need: 
Authentication * 

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© 2014   Yuma Regional Medical Center  |  2400 S. Avenue A  |  Yuma, AZ 85364  |  928-344-2000