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Preregister for your visit to Unity Hospital

At Unity Hospital, we encourage all patients to preregister. This way, your paperwork can be prepared before you arrive, and we can expedite your check-in process.

To preregister for a test or procedure scheduled at Unity Hospital, please 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.

If you have questions or would like to preregister by telephone, call the Allina Health preregistration department at 612-262-7878 or 1-888-660-0014.

Please note: Online preregistrations are entered Monday-Friday, 8 a.m. to 4:30 p.m.
Please preregister at least one full business day before your appointment.

If your appointment is less than one full business day away, do not use this form. Please preregister by calling the Allina Health preregistration department at 612-262-7878 or 1-888-660-0014.

Allina Health is committed to maintaining an organization-wide tobacco-free environment. The use of tobacco products is prohibited on all Allina Health owned and leased premises. Please remember to leave your valuables at home (jewelry, cash, etc.)

* 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:  


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