Hospital Pre-Registration Form (English)


Thank you for choosing El Campo Memorial Hospital for your next medical visit. By completing this pre-registration form, you can receive peace of mind that we have your medical information for your upcoming services. 

Complete the following information as accurately as possible. This form should take 4 or 5 minutes to complete. To submit your information simply click the "Submit Form" button to complete your pre-registration process. (*) Required information is necessary.

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Patient Full Name(Required)
First Name, Middle Initial, Last Name (Required)
Address(Required)
Area Code and 7 Digit Number
Marital Status(Required)
Sex(Required)
Race(Required)
Employment Status
If you are employed please list your major employer's business name.
Employer's Street Address
Area Code Plus 7 Digit Number
Fill In This Field Only If You Expect To Retire.
How Do You Plan To Pay?(Required)

Responsible Party Information

Fill Out Below If The Patient Is Not The Responsible Party
MM slash DD slash YYYY
Address
Area Code and 7 Digit Number
Area Code and 7 Digit Number
Sex
If you are employed please list your major employer's business name.
Employer's Street Address
Please Type In Full Name, Relationship, Area Code & Telephone Number (Required)
May we discuss personal information with this person?(Required)
Health Care Coverage(Required)
(Payment Arrangement Contract)
Name of Primary, Secondary and Third Insurance if applicable.
Policy/Identification Number and Group Number of Primary, Secondary, and Third Insurance if applicable.
9 Digit Number and Letter
Type Of Medicare Coverage
In Patient, Out Patient, Or Both
This number may contain letters.

Medicaid Manage Care

Please Note MMC is NOT in Network with Amerigroup or Evercare All Services Will Require Prior Authorization. Please contact the admitting office to verify in network benefits.
9 Digit Number (CHIPS ID Number may contain a letter)
Financial Assistance Program
El Campo Memorial Hospital offers financial assistance for qualified Wharton County residents.
Type Of Service(Required)
Please provide your scheduled appointment date if available.
Doctor who signed the Order (Required)
Family Physician
This field is for validation purposes and should be left unchanged.
El Campo Memorial Hospital (ECMH) and its predecessor have been providing the highest quality medical care in El Campo for over 68 years, and at the current location since 1979.The hospital is accredited by state and federal regulations (Medicare/Medicaid). Patient Billing: Various physicians involved in your care at ECMH will bill you directly for their services. These may include your anesthesiologist, emergency room physician(s), radiologist, pathologist, cardiologist or other consulting physician during your ER visit or hospital stay. Please remember that some physicians are private practitioners (contracted by ECMH and not an actual employee of ECMH) and may not be a provider on your specific managed care plan.