WC Registration Form

Baylor Scott & White Medical Center Frisco
5601 Warren Parkway
Frisco, TX 75034

Women's Center Registration Form

Completion of this form allows us to register you & file with your insurance.

NOTE: * Denotes Required Field.

Registration Type: *

Women Center Registration (Labor and Delivery)

Patient Information:

Patients Name: *

First Name Last Name

Patients Date of Birth: *

Month Day Year

Gender: *

Male Female

Patients Address: *

Street Address:
Apt. # (if applicable)
City	State
Zip Code	Country

Patients Phone #: *

Area Code Phone Number

Patients E-mail: *

Patients Marital Status:

Married Single Divorced

Social Security #: *

Race: *

Religion:

Are you of hispanic origin: *

Yes No

Primary Family Physician: *

Family Physician Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Family Physician Phone #:

Area Code Phone Number

Patients Employer Name: *

Patients Employer Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Patients Employer Phone #: *

Area Code Phone Number

Patients Occupation:

Employee Status:

Full-Time Part-Time Unemployed Retired Active Military Duty Student Unknown

Next of Kin:

Name: *

Address (if different then Patient):

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone #: *

Area Code Phone Number

Relationship to Patient: *

Person to Notify:

Same as Next of Kin (If no, please fill out below): *

Yes No

Name:

Address (if different then Patient):

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone #:

Area Code Phone Number

Relationship to Patient:

Guarantor Section:

Is patient a minor (If no, skip guarantor section): *

Yes No

Guarantor Name:

First Name Last Name

Guarantor Date of Birth:

Month Day Year

Guarantor Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Guarantor Phone Number:

Area Code Phone Number

Guarantor Email:

example@example.com

Guarantor Social Security #:

Relationship to Patient:

Guarantor Employer Name:

Guarantor Employer Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Guarantor Phone Number:

Area Code Phone Number

Guarantor Occupation:

Guarantor Employee Status:

Full-Time Part-Time Unemployed Retired Active Military Duty Student Unknown

Insurance Provider Information:

Insurance Provider: *

ID #: *

Group #: *

Policy Holder Name: *

First Name Last Name

Policy Holder Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Policy Holder Date of Birth: *

Month Day Year

Policy Holder Social Security #:

Policy Holder Relationship to Patient: *

Policy Holder Employer Name:

Policy Holder Employer Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Do you have any sensory or physical impairments (If yes, please explain below): *

Yes No

Physical Impairments:

Secondary Insurance Provider Information:

Do you have a secondary insurance (If no, please skip): *

Yes No

Insurance Provider:

ID #:

Group #:

Policy Holder Name:

First Name Last Name

Policy Holder Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Policy Holder Date of Birth:

Month Day Year

Policy Holder Social Security #:

Policy Holder Relationship to Patient:

Policy Holder Employer:

Policy Holder Employer Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Baby Insurance Provider Information:

Whose Insurance plan will the baby be covered under: *

Mother Father

Insurance Provider: *

ID #:

Group #:

Policy Holder Name:

First Name Last Name

Policy Holder Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Policy Holder DOB:

Month Day Year

Policy Holder Social Security #:

Policy Holder Relationship to Patient:

Patient Information Continue:

Date of Patients Last Menstrual Period:

Month Day Year

Obstetrician's Name: *

Do you have any Advance Directive documents (If yes, please select all that apply):

Advance Directive Medical Power of Attorney Living Will DNR Mental Health Directive

Location of These Documents:

Expected Date of Delivery: *

Month Day Year

To expedite your check-in process, please have your Current Insurance Card and Picture ID available.

The document(s) accompanying the registration form contains(s) confidential information belonging to the author that is legally privileged. The information is intended only for the individual or entity named above. If you are not the tntended recipient, you are herby notifed that any disclosure, copying, distribution, or taking of any action in release of the contents of this information is strictly prohibited. If you have received this registration form in error, please notify us by telephone immediately to arrange for the return of the original documents to Baylor Medical Center at Frisco.