Welcome to our OB Preregistration form. This online form is an alternative to filling out the paper form normally provided by your physician in the third trimester of your pregnancy. Hopefully you will find this a time-saving and convenient method of providing Advocate Health Care with the information we will need in order to register you when you arrive at the Hospital to give birth.
To allow for adequate processing time, please fill out this form during your second or third trimester at least 30 days prior to your expected due date.
Before you begin, please have the following information ready:
Your insurance cards
The insurance plan(s) policyholders' employment information (business name, address and phone)
Phone numbers for yourself and family members
Dates of birth and social security numbers for yourself and the policyholder(s) for your insurance plan(s)
The name of the obstetrician involved in your care
For questions or comments about this form please send an email to:
We Keep Your Information Private
Advocate Health Care has always supported and recognized our patients' right to expect that their medical records and other information about their care will be kept confidential. For the past two years Advocate Health Care has been preparing to implement policies and procedures to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Regulations.
What is HIPAA and what does HIPAA mean to patients? The HIPAA privacy regulations give patients more control over their health information and also set boundaries on the use and release of patient information. The regulations also establish appropriate safeguards that all health care providers must achieve to protect the privacy of health information.
One of the provisions of the HIPAA privacy regulations is that all health care providers distribute a
Notice Of Privacy Practices
to patients. Advocate Health Care patients will begin receiving our Notice on April 14, 2003. All patients will be given a
Rights and Responsibilities Notice in
. when they register for patient services at any of the Advocate Health Care facilities. Patients are not required to read the Notice, but are being asked to sign an acknowledgement that they received the Notice, as is required by the privacy regulations. You can save some time by printing and signing this form now and bringing it with you to the hospital. Additionally, we ask that you print out and sign our
Consent Form in
. Please print and sign multiple copies as seperate forms are required for you and for each infant.
Continue Saved Registration
Patient Last Name
Patient First Name