IUHealth EForms

Bloomington Pre-Registration Form

REASON FOR VISIT

Which of the following best defines the purpose of your upcoming visit?

PATIENT INFORMATION

Personal Information

Why are we asking this? IU Health wishes to respect your religious/spiritual needs, so we need to be aware of any affiliations you may have

Contact Information

Relative Information

Other Information

INSURANCE INFORMATION

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:

Medicaid
Other Healthcare Insurance
Additional Insurance
Additional Insurance

SUBMISSIONS

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.

REMINDERS

Please remember to bring with you to the hospital -

All signed written physician/provider orders that have been provided to you.

Insurance card(s)

Any applicable referrals or authorizations.

Picture ID (ex. Driver's License, Passport).

A list of all your current medications.