Skip to main content
You are here: Home > Owatonna Hospital  
 

Pre-register for your visit to Owatonna Hospital

At Owatonna Hospital, we encourage all patients to pre-register for scheduled services to ensure a faster check-in process. Please pre-register at least one week prior to your appointment. If your appointment is less than five business days away and we have not received your online pre-registration a representative of our Business Services Department will be contacting you to pre-register by telephone. If you have any questions, please call 507-451-3850.

To preregister online simply fill out the form below.

  • Make sure all required fields (*) are filled in.
  • If a required field does not apply to you, type in "NA" or "Not Applicable."
  • Fill in as many fields as possible so we can best prepare your registration.
  • Please bring your insurance card with you.

This site uses a secure server to encrypt all your personal information and protect your confidentiality and privacy. See our privacy policy.

* indicates required field

* What date will you be arriving for services? Month Day Year (or due date)  
  Personal Physician or Family Physician Name: Last
First
 
* What procedure/test are you having done?  
 
Patient Information
  Legal Name
*    Last:  
*    First:  
     Middle:  
  Social Security Number: - -  
  Marital Status:
 
* Sex:
  Race: (Required for Government reporting and medical research)
 
     Country of origin:  
* Date of Birth Month Day Year  
Mailing Address
* Street:  
* City:  
*State:  
* Zip:  
  County:  
* Phone Number:  
* Employment Status:
 
  Retirement Date:  
  Employer:  
  Occupation  
  Work Phone:  
  Employer Address [City , State, Zip]:  
 
Guarantor Information
[Person responsible for the bill. If the patient is the guarantor skip this section and go to Spouse Information]
Relation to Patient:  
Guarantor Name:
     Last:  
     First:  
     Middle:  
  Sex:  
  Date of Birth: Month Day Year  
  Social Security Number:  
  Marital Status:
 
  Guarantor Mailing Address  
  Street:  
  City:  
  State:  
  Zip:  
  County:  
  Employment Status:
 
  Employer:  
  Work Phone:  
  Employer Address [City , State, Zip]:  
    
Spouse Information
  Spouse Name:  
     Last:  
    First:  
    Middle:  
 Date of Birth: Month Day Year  
 Social Security Number:  
 Employment Status:
 
  Employer:  
  Work Phone:  
 Employer Address [City , State, Zip]:  
    
Emergency Contact Information (Other than listed above)
  Emergency Contact Name:
   Last:
First:
 
  Relation to Patient:  
 Day Phone:  
 Evening Phone:  
 
Accident Information
[To be filled out if this visit/admission is the result of an accident]
 Type of Accident:
 
  Date of Accident: Month Day Year  
  Place of Accident/Injury:  
  Body Part Injured:  
  Nature of Accident:  
  Claims Address:  
  Claim Number:  
  Agent/Claims Adjuster:  
  Claim Phone:  
 
Insurance Information - Primary
  Name of Insurance Company:  
  Policy Holder Name:  
  Relationship to Patient:  
  Group/Account Number:  
  Policy/ID Number/Claim Number:  
 
Insurance Information
  Do you have Medicare:  
  Effective Dates: Part A
Part B
 
  Are you entitled to Medicare based on:  
  Do you receive black lung medical benefits?  
  Will your services be paid by government program other than Medicare/Medicaid?  
        If yes, please
     explain
 
 
Secondary Insurance Information
  Name of Insurance Company:  
  Policy Holder Name:  
  Relationship to Patient:  
  Group/Account Number:
  Policy/ID Number:  
  Eligibility /Benefit /Customer Service Number:  
  Insurance Company Address:  
  Additional Information:  


This site uses a secure server (SSL) to encrypt all of your personal information. We use strong security measures to protect and prevent the loss of your information.