Bloomington Pre-Registration Form
REASON FOR VISIT
If you DO NOT have health insurance coverage and would like to speak to someone regarding payment options, please call 812.353.5300 and choose Option 1 to speak to a Financial Counselor. If you would prefer that we contact you, please check the box below:
Thank you for completing this online process. We do appreciate your time and anticipate that by completing this form, we will be able to provide you with a better service experience during your visit.
Please remember to bring with you to the hospital -
All signed written physician/provider orders that have been provided to you.
Any applicable referrals or authorizations.
Picture ID (ex. Driver's License, Passport).
A list of all your current medications.