Patient Registration

To register for your upcoming procedure, please provide the requested information in the following sections:

  1. Patient Information
  2. Emergency Contact Information
  3. Insurance Information
  4. Billing Information
  5. Procedure Information

1 Patient Information

Employer Information

2 Emergency Contact Information

3 Insurance Information

Primary Insurance Information

Secondary Insurance Information

4 Medical Charges

Person Responsible for Hospital Charges

5 Procedure Information

Anticipated date to be admitted to Springhill Medical Center?

6 Review

Please review the information you have entered to ensure it is accurate before submitting the registration.

* It is extremely important that you bring your Driver's License, Insurance cards, and Physician Orders at the time of your service.

Please feel free to contact the Pre-Registration Office at 251.460.5240 at any time between the hours of 8:00 a.m. - 5:00 p.m. on Monday-Friday, if you have any questions about your registration or if we may be of assistance to you in completing this form.