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Patient Pre-Registration

Pre-Register for your test or procedure

Welcome to Valley View Hospital's online Pre-Registration. If you have a test or procedure scheduled, please fill out the following form in its entirety. Please note that fields marked with an asterisk (*) are required to be filled in. This form will not submit if one of these fields is left blank. If the question for a required field does not apply to your situation, please enter “NA" or "Not Applicable". Please fill in as many fields as possible - the more questions you answer for us, the better we are able to serve you.

If you have questions about the online pre-registration process or would prefer to pre-register by telephone, please call the Valley View Hospital Communications Department at (970) 384-6861.

All information submitted in this Pre-registration site is maintained as confidential and secure.

Valley View Hospital respects your private and personal health information. We maintain confidentiality and security as required by Federal HIPAA Guidelines. Our staff is skillfully trained to secure and keep your personal health information private. Please contact the Privacy Office at 970-384-6810 if you have any concerns about your privacy.

Please Note: Online pre-registrations are checked Monday-Friday, 8 a.m. to 4:30 p.m. Please allow at least one full business day before your appointment for your pre-registration form to be processed. If there is less than one full business day before your appointment, please pre-register by calling the Valley View Hospital Communications Department at (970) 384-6861.

Move forward to any field by clicking with your mouse or using your Tab key.

Patient Information           

  ** Information Required    
Patient New to Valley View?:   Yes    No
 
Patient's Last Name**:   Patient's First Name**:   MI:
   
Patient's Street Address**:   Birth Date (month, day & year)**:
     
City**:   State**:    ZIP Code**:
    
Telephone Number(###-###-####)**: Social Security Number(###-##-####)**:
Email:
Marital Status: Gender:   
Patient's Race:
Other Name You Have Used in the Past (i.e. maiden name):
Patient's Employer:   Employment Status:
 
Employer's Street Address:Employer's Phone:
City:   State:    ZIP code:
    


 Guarantor Information

The guarantor is the person who is guaranteeing payment (usually the same as the patient if the patient is over age 18). Is the patient the guarantor?

 Yes   No
 
Guarantor's Name:
Guarantor's Street Address:
Guarantor's City:   State:      ZIP code:
    
Guarantor's Telephone Number(###-###-####): Social Security Number(###-##-####):
Guarantor's Email:
Relationship to Patient(Guarantor):
Guarantor's Employer:   Guarantor's Employment Status:
 
Guarantor's Occupation
Employer's Address:Employer's Phone(###-###-####):
City:   State:        ZIP Code:
    
 

Primary Insurance?    Yes    No

Please bring your insurance card with you to your appointment so that we can make a copy of it.
 
Primary Insurance:
 
Insurance Company Street Address:
City:   State:        ZIP Code:    
         
Company's Telephone Number(###-###-####): Company's Email:
Is patient the policyholder?   Yes   No
 
Name of Policyholder:
 
Policyholder's Address:Policyholder's Phone:
City:   State:        ZIP Code:
    
Policyholder's Birth Date (month, day & year):   Policyholder's Gender:    
     
Policyholder's Marital Status   Policyholder's Race
 
Policyholder Social Security Number(###-##-####):   Group/Employer Name:
 
ID/Policy/Subscriber Number: Group Number:
 

Secondary Insurance?    Yes    No

Please bring your insurance card with you to your appointment so that we can make a copy of it.
 
Secondary Insurance:
 
Insurance Company Street Address:
City:   State:        ZIP Code:    
          
Secondary Company's Telephone Number: Secondary Company's Email:
Is patient the policyholder?   Yes   No
 
Name of Policyholder:
 
Policyholder's Address:Policyholder's Phone:
City:   State:        ZIP Code:
    
Policyholder's Birth Date (month, day & year):   Policyholder's Gender:    
       
Policyholder's Marital Status:   Policyholder's Race:
 
Policyholder's Social Security Number(###-##-####):   Group/Employer Name:
 
ID/Policy/Subscriber Number: Group Number:
 

Emergency Contact Information

First Emergency Contact (Next of Kin):
Next of Kin's Relationship to Patient:
Next of Kin's Street Address:
City:   State:         ZIP Code:
     
Next-of-Kin's Home Phone(###-###-####): Next-of-Kin's Work Phone(###-###-####):

Second Emergency Contact:
Secondary Contact's Relationship to Patient:
Secondary Contact's Street Address:
City:   State:         ZIP Code:
     
Secondary Contact's Home Phon(###-###-####)e: Secondary Contact's Work Phone(###-###-####):
 

Just a Few More Questions...

Physician's Name
Reason for Visit:
   
 Accident:
 Yes    No
Date of Visit (MM/DD/YY):
Is patient covered by Medicare?
Yes    No

 

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Valley View Hospital
1906 Blake Ave
Glenwood Springs, CO 81601
(970) 945-6535

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