Pre-Registration: Imaging

Imaging Pre-Registration

Kindly complete this form to begin the pre-registration process for your imaging service(s) at Doctors Hospital
Kindly complete this form to begin the pre-registration process for your imaging services at Doctors Hospital.

DISCLAIMER: Please complete this form if you have secured an appointment at Doctors Hospital Imaging Services. If not, please contact the Imaging Department at (242)-302-4610 ext. 4662, 5135.

DEADLINE:This form must be sent at least 48 hours before from the date of service.

DOCTORS HOSPITAL PREREGISTRATION DEPARTMENT

Telephone Contact(s):

Direct Pre-Registration Line:(242)-302-4748 (Mondays-Fridays, Hours: 9 a.m. - 5 p.m.)

Main Patient Registration Line: (242)-302-4610/4734

Email: preregistration@doctorshosp.com

Documents

Please be prepared to upload, if necessary, the following documents for your pre-registration.
- Patient Government Issued Photo-ID
- Insurance Card (if applicable)
- Imaging Requisition Form (if available)
- Guarantor Government Issued Photo ID (if applicable)
- Guarantee of Payment Letter (if applicable) Requirements: Stamped, Dated, Signed on a letterhead Must include the name of the imaging procedure(s)
Depending on your selections, these documents may be required in order to complete this pre-registration form.
Terms & Conditions
MAMMOGRAM PATIENTS:
1. Please note that Mammograms no longer take place on Saturday or Sunday, unless scheduled by a Doctors Hospital's Imaging Clerk.

Patient Demographics

Please review your answers before moving on to the next page.
YesNo
YesNo
Full Name:*

First NameMiddle NameLast Name
Date of Birth:*

MonthDayYear
Marital Status:*
Gender:*
Age:*
NIB Number:*
If you do not have a NIB number, enter "0"
Email Address (will be used for important correspondence regarding pre-registration):*

Confirmation EmailPlease enter the email address twice to ensure that the correct email is entered.
Home Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number:
Please enter a valid phone number.Format: (000) 000-0000.
Address:*

Street Address

Street Address Line 2

City/SettlementState/Province/Island

Postal / Zip Code (if none, enter "0")Country

Employer Information

Please review your answers before moving on to the next page.
EmployedSelf-EmployedUn-Employed
Name of Employer:*
Job Title:*
Employer Address:*

Street Address

Street Address Line 2

City/SettlementState/Province/Island

Postal / Zip Code (if none, enter "0")Country
Employer Contact Number:*
Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact

Please indicate persons to contact in the case of an emergency.
Primary Contact
Full Name:*

First NameMiddle NameLast Name
Relationship to Patient:*
Home Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number:
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Address:*

Street Address

Street Address Line 2

City/SettlementState / Province/Island

Postal / Zip Code (if none, enter "0")Country
Secondary Contact

It is a requirement that each patient has two (2) emergency contacts on file.
Full Name:*

First NameMiddle NameLast Name
Relationship to Patient:*
Home Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number:
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Address:*

Street Address

Street Address Line 2

City/SettlementState / Province/Island

Postal / Zip Code (if none, enter "0")Country

Imaging Details

Physician & Imaging Services
NOTE: If you have multiple services on the same day and at different times, please select the time of your earliest imaging service.
Please select the date and time of your imaging service(s):*
NOTE: If you have multiple services on the same day and at different times, please select the time of your earliest imaging service.
Name of ordering physician:*
Name of physician requesting the imaging orders.
YesNo
Imaging Services

Please list all your imaging service(s) below.
Please add the imaging service(s) by selecting 'ADD' after filling out the three (3) fields below. You may delete or edit all selections. *
* If you are not sure whether the service is with contrast, please indicate by 'N/A' PLEASE SEE THE FOLLOWING BELOW AS EXAMPLES: EXAMPLES IMAGING SERVICE(S) BODY LOCATION USING CONTRAST EXAMPLE 1 MRI LEFT KNEE YES EXAMPLE 2 MAMMOGRAM BOTH BREASTS NO EXAMPLE 3 BONE SCAN WHOLE BODY NO EXAMPLE 4 CT SCAN ABDOMEN YES EXAMPLE 5 ULTRASOUND KIDNEY NO EXAMPLE 6 PULMONARY PERFUSION LUNGS NO

Method of Payment

Please review your answers before moving on to the next page.
LAMP (Loyalty Advantage Membership Program) ONLYNational Health Insurance (NHI)Self-Pay (Out of Pocket)Company- with Doctors Hospital credited account (e.g. National Insurance Board)Insurance
YesNo
Please state the name of the accredited company responsible for your imaging fees:*
YesNo

Guarantor Agreement

The Guarantor must be an individual 18 years or older.
YesNo
Guarantor Details

Please complete the following information of the individual who is financially responsible for the patient, pertaining to the indicated healthcare service(s) sought out as a result of this form submission. Person must be 18 years or older.
NOTE: Please note that even though you, the patient, may pay off your account balance andor all bills concerning services obtained for this submission, it is Doctors Hospital's policy that a Guarantor, other than yourself, is listed for your account.
Guarantor's Name:*

First NameLast Name
Relationship to Patient:*
Guarantor's NIB#:*
Home Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number:
Please enter a valid phone number.Format: (000) 000-0000.
Guarantor's email address:*

Confirmation EmailPlease enter the email address twice to ensure that the correct email is entered.
Guarantor's Signature:*

Clear
By signing this, I accept financial responsibility of the patient

Method of Payment

Insurance Details
YesNo
YesNo
Primary Insurance Carrier

NOTE: For children, the father's insurance is the primary insurance carrier.
Name of the Insured:*
Relationship to Patient:*
Insured's Employer:*
Name of Group Plan. If an individual plan, state 'individual'.
Primary Insurance Carrier:*
Name of Insurance Company
Certificate Number:*
Member Identification Number.
Secondary Insurance Carrier
Name of the Insured:*
Relationship to Patient:*
Insured's Employer:*
Name of Group Plan. If an individual plan, state 'individual'.
Secondary Insurance Carrier:*
Name of Insurance Company
Certificate Number:*
Member Identification Number.
Digital Insurance Form

Kindly complete and submit this form. Failure to complete your insurance form will result in a hold on your account until it has been successfully received with the appropriate signatures.
Digital Insurance Form

Please complete the following form below:
Please ensure that "Patient's Signature" and "Insured's Signature" have your signatures. Failure to do will result in a hold on your account.
- Please click "Start Filling" to complete the form.
- Once you click "Submit", please wait for the Confirmation Page to appear, confirming that your submission was successful (you will see this confirmation page once you click "Submit"):
EXAMPLE:
YesNo

File(s) Upload

Please review your answers before moving on to the next page.
Patient Government-Issued Photo Identification:*

Accepted File Formats: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Cancelof
Imaging Requisition Form:*

Accepted File Formats: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Cancelof
Discount Coupon:*

Accepted File Formats: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Cancelof
Insurance Card(s):*

Accepted File Formats: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Cancelof
Guarantor Government-Issued Photo Identification (individual must be 18 years or older):*

Accepted File Formats: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Cancelof
Guarantee of Payment Letter:*

Accepted File Formats: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Cancelof

Terms & Conditions

Please read the below terms carefully.
Patient Signature:*

Clear
By signing this, I hereby agree to all the terms and conditions listed above.
Guarantor Signature:*

Clear
By signing this, I hereby agree to all the terms and conditions listed above.

Email Correspondence
After you submit your registration form, you will receive an email from us.

It is important that you check your email to ensure that you have received an email from our team.
Should be Empty:

Imaging Pre-Registration

Documents

Terms & Conditions

Patient Demographics

Employer Information

Emergency Contact

Primary Contact

Secondary Contact

Imaging Details

Imaging Services

Method of Payment

Guarantor Agreement

Guarantor Details

Method of Payment

Primary Insurance Carrier

Secondary Insurance Carrier

Digital Insurance Form

Digital Insurance Form

File(s) Upload

Terms & Conditions

Email Correspondence