Welcome to Online Registration
 
Registration on-line allows you to pre-register at your convenience 48 hours prior to your scheduled appointment. Providing information before you arrive will help minimize your registration time the day of your service.

Please Note: Allow two (2) days before your appointment for processing this form. If it is less than 2 days before your appointment/service, please call Centralized Scheduling at 304-424-2778, Monday through Friday from 730am 800pm or on Saturday from 900am 100pm.

All fields must be completed. If a field does not apply, enter "NA". If you are unsure how to complete a field, enter "?" or call Centralized Scheduling during regular business hours.

To ensure proper insurance verification, please bring your insurance cards with you to your appointment.

Medicare patients If additional information is required we will contact you to complete
the registration.

For your protection, all information is kept confidential, and the online form contains security precautions (data is encrypted for transmission)
Patient Information
 
Last Name:
First Name:
Middle Initial:
 
 
Maiden Name:
  Mother's First Name:
 
 

(This information helps us identify the Medical Record)

 
 
 

 
 
 
Date of Birth:
Age:
Sex:
 
 
 
  
 
    
 
 
Street Address:
 
 
 
City:
State:
Zip:
 
 
 
      
 
 
Mailing Address:
 
 
 
City:
State:
Zip:
 
 
 
Home Phone:
Other Phone:
 
 
 
  
 
    
 
Marital Status:
Race:
 
 
 
Social Security #:
Religion:
 
   
 
Employer        Name:
 
       
 
Address:
 
 
City:
State:
Zip:
 
 
Employment Status:
Height:
Weight:
Are you a Veteran?
 
           
 
Spouse's Name:
 
 
Spouse's Employer:
 
           

Next of Kin (First Contact)
Name:
   
 
City:
State:
Zip:
   
 
Home Phone:
Work Phone:
   
 
Relation to Patient:
   

Person to Notify (Second Contact)
Name:
   
 
City:
State:
Zip:
   
 
Home Phone:
Work Phone:
   
 
Relation to Patient:
             
Insurance Information
 
Insurance Name:
   
 
Address:
   
 
City:
State:
Zip:
   
 
Phone Number:
Policy Number/ID Number:
   
 
Group/Employer:
Group Number:
   
 
Subscriber Name:
   
 
Subscriber Address:
   
 
City:
State:
Zip:
   
  Subscriber Birthdate:
Relation to Patient:
   
 
Employment Status:
       
             
Maternity Patient Information
 
Last Period Date/Maternity Related:
Expected Delivery Date:
   
 
OB Physician :
Family Physician :
   
             
Guarantor Information
*Do not need to complete if patient is over 18 years of age. If under 18 years of age this will be custodian information.
 
Name:
Social Security # :
   
 
Address:
   
 
City:
State:
Zip:
   
 
Home Phone:
       
 
Employer Name:
   
 
Address:
   
 
City:
State:
Zip:
   
 
Work Phone:
Relation to Patient:
   
             
Service Information
 
Type of Procedure:
X-ray:
Lab:
Other:
   
 
Ordering Physician Name (Last, First)
   
 
Reason for Exam:
   
 
Expected Date of Service
   
 
Is this service related to an accident?
Yes:
No:
   
 
Date of Accident:
Time of Accident:
   
 
Type of Accident:
Work Related:
Auto Accident:
Other Party Liable:
   
 
Liable Party:
   
 
How did the accident happen?
   
 
Where did the accident happen?
   
             
 

Click the submit button below to securely send your pre-registration information to our admitting staff.

 

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Camden-Clark Memorial Hospital
800 Garfield Avenue
Parkersburg, WV 26101


To meet the health care needs of the community for a lifetime.

This web site will provide you with a overview of the services available to you through Camden-Clark Memorial Hospital.  It is also designed to answer commonly asked questions.  If you have any questions, feel free contact us at (304) 424-2111 or e-mail us at prccmh@ccmh.org