Online Patient Pre-Registration Form - McLaren Northern Michigan

McLaren Northern Michigan Online Patient Pre-Registration Form

To pre-register for your visit to McLaren Northern Michigan, please follow these simple steps:

  1. Complete the form below as completely as possible and submit. If your appointment date should change, or even be canceled, there is no need to contact the hospital.

  2. On the day of your appointment, please enter the facility based on the campus, service and time you are coming:

    Petoskey Campus
    • Surgery - come to the Surgery Entrance off of Connable
    • Medical Imaging or Lab Test - come to the Main Entrance off of Jackson Street

    Cheboygan Campus
    • Surgery - come to the Emergency Entrance before 6:30 am; the Medical Office Building Entrance after 6:30 am
    • Lab Tests - come to the Medical Office Building Entrance
    • Medical Imaging Test - come to the Emergency Entrance

  3. All dates must be entered in mm/dd/yyyy format.

  4. This is a secured webpage.

    *Indicates required information
  
  
  
  
  
  
  
  
  
  
  
  
  
  
   
  
  
  
  
  
  
Appointment Information:

  

  

  
(Last,First) 

  
Patient Information:







 


please note:: if you do not provide your social security number, your Mothers Maiden Name will be required. This is for your safety and to secure your identity.











 

Email is used for patient portal invitation

 






 




 

 



  





  

Insurance Information:
Primary Insurance - Workman's Comp/Auto Insurance (Please enter numbers as they appear on the card):

(if you do not have insurance, please write self-pay and put an X in the remaining fields


(if you do not have insurance, please write self-pay and put an X in this field)


(if you do not have insurance, please write self-pay and put an X in the remaining fields)


(if you do not have insurance, please write self-pay and put an X in the remaining fields)


Subscriber/Policyholder Information



 



   
Secondary Insurance Information:




Subscriber/Policyholder Information:
 



 



   
Tertiary Insurance Information:




 Subscriber/Policyholder Information:



 



 
Please confirm with your insurance carrier on authorization or referral requirements for this visit:


Additional Medicare Questions:









Age






Disability







End Stage Kidney Disease (ESRD):






Emergency Contact Information:












If you have questions, please call our office at 231-487-3445 or toll free at 866-652-0992 Monday - Friday from 9 am until 1 pm; between 1 - 5 pm, call 231-487-5525. Thank you for choosing McLaren Northern Michigan for your healthcare needs. By submitting this form you have pre-registered for your upcoming procedure.