Welcome to South Nassau

Secure Online Registration Form

* - denotes a required field
 Do you have an Advance Directive? YES  NO
 If YES, is it on file with SNCH? YES  NO
 Is this visit related to:
Motor Vehicle Accident?   YES  NO
Work Related Accident?   YES  NO
  If YES, please see Registrar for additional required form.
 Patient Information
* Last Name * First Name
MI * Date of Birth mm/dd/yyyy
Age * Sex M  F
* Social Security # * Marital Status M  D  
S  W
Translator Needed? YES  NO Place of Birth
* Race Religion
Ethnicity Preferred Language
Mother's Maiden Name Father's First Name
* Address City
State Zip code
* Home Tel.# Cell Phone#
* Email Address
 Emergency Contact Information
* Emergency Contact Name  Next of Kin Name
* Relationship  Relationship
Address  Address
* Tel.#  Tel.#
 Employer Information
Patient Employer's Name Employer's Address
Employer's Tel.# Employer's Fax#
Patient Retired? YES  NO Retire Date  mm/dd/yyyy
Disabled? YES  NOEffective Date:  mm/dd/yyyy
Spouse's Name: Spouse's Retire Date:  mm/dd/yyyy
 Primary Insurance
Insurance Name ID #
Group # Ins Tel.#
Ins. Billing Address  
Policyholder's Name Relationship to Patient
Policyholder's Employer Policyholder's DOB
 Secondary Insurance
Insurance Name ID #
Group # Ins Tel.#
Ins. Billing Address  
Policyholder's Name Relationship to Patient
Policyholder's Employer Policyholder's DOB
 Procedure Information
* Exam Date mm/dd/yyyy Time
Exam Type Diagnosis
* Doctor/referring * Doctor Phone
Address Expected Date of Delivery
(if applicable)
 mm/dd/yyyy
 
PLEASE CALL YOUR DOCTOR'S OFFICE AND REQUEST THAT THEY HAVE YOUR PROCEDURE/TEST OR STAY/VISIT AUTHORIZED.

PLEASE HAVE PHOTO I.D. AND ALL INSURANCE CARDS AVAILABLE AT TIME OF SERVICE.


 
 If you have any questions or need help completing this form, please call:
Inpatient/Maternity: (516) 632-3901 Outpatient: (516) 632-3991 Radiology: (516) 632-3921

Compliance and Privacy Policies for Vendors and Patients
• © 2013 South Nassau Communities Hospital • One Healthy Way • Oceanside, NY 11572
• 1-877-SouthNassau (877-768-8462)

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