Coronavirus

Sidney Regional Medical Center

308.254.5825 /

Welcome to SRMC
Careers
Pay Online
Health Center Foundation

Search

I want to...
Our Services
Find a Provider
Patients & Visitors

My Health Connection

I want to...
Our Services
Find a Provider
Patients & Visitors

Patients & Visitors

A A

Preparing for your visit

Preparing for your visit
Patient feedback
Why access your patient portal?
Web nursery
Send a greeting
Safety precautions
Visitor guide
Local support and resources
Patient Billing Resources

Processing...

Pre Admit Online Registration Form

Please complete each section to the best of your ability and then select the "Next" button to complete each page.

Service Date (mm/dd/yyyy)

Clinic/Service

Provider (Select if known)

Patient Information

Patient Last Name

Patient First Name

Patient Middle Name

Patient Maiden Name (if applicable)

Mailing Address

City

State

Zip

Primary Phone Number

Email Address

Patient Date of Birth (mm/dd/yyyy)

Sex

Marital Status

Military

Tobacco User

Religion

Race

Ethnicity

Language

Please press "Next" to continue to page 2.

Employer Information (if patient is a minor, use parent/guardian information)

Employer Name

Employer Address

Employer Phone Number

Emergency Contact Information

Emergency Contact Name

Emergency Contact Address

Emergency Contact Phone Number

Relationship to Emergency Contact

Primary Insurance Information

Primary Insurance Name

Primary Insurance Group Name

Primary Insurance Group Number

Primary Insurance Subcriber Information (policy holder)

Primary Insurance Subscriber Full Name

Primary Insurance Subscriber Relationship to Patient

Primary Insurance Subscriber Sex

Primary Insurance Subscriber Date of Birth (mm/dd/yyyy)

Secondary Insurance Information (if applicable)

Enter Secondary Insurance Name

Enter Secondary Insurance Group Name

Enter Secondary Insurance Group Number

Secondary Insurance Subcriber Information (policy holder)

Secondary Insurance Subscriber Full Name

Secondary Insurance Subscriber Relationship to Patient

Secondary Insurance Subscriber Sex

Secondary Insurance Subscriber Date Of Birth (mm/dd/yyyy)

Please press "Next" to continue to page 3.

Conditions of Admission and Consent to Treatment

CONSENT TO TREATMENT. I hereby request and consent to routine clinical, emergency hospital and medical care for the patient (and the patient’s newborn child in maternity cases) including all routine examinations, tests including HIV testing as described below , photographs and other procedures. Any tissue removed may be disposed of in Sidney Regional Medical Center (SRMC)’s customary manner. I acknowledge that no guarantees have been made as to the results of such clinical, hospital and medical care. I understand a patient has the right to refuse treatment and that my signature below is not consent to any special medical or surgical procedure. In the event that such procedures are recommended, it is the physician’s responsibility to explain the nature of the procedure, the reason it is recommended and the risks associated with the procedure. The physician and/or member of the nursing staff may ask the patient to sign a form confirming consent to the recommended procedure and alternatives to the procedure. Patients are encouraged to insist on any additional information necessary to make an informed decision to consent to or refuse treatment. No patient will be involved in any research or experimental procedure without his or her full knowledge and consent.
CONTINUING OUTPATIENT CARE. In some cases, proper treatment of a medical condition requires treatment or diagnosis over a course of repeated outpatient visits. In such cases, the request, consent, and agreements contained here shall apply to all repeat visits and all continuing treatment and diagnosis for the same condition.
ASSIGNMENT OF INSURANCE BENEFITS. I hereby assign to SRMC, for services provided by SRMC and Physicians Clinics and their employees and others working under contract or arrangement with SRMC, all coverage or other benefits available under any government program, insurance policy or plan, or any other benefits program, and I direct that all benefits be paid directly to SRMC. I agree that SRMC may receive benefits directly, which will discharge the insurer or benefit program to the extent of such payments. Any credit balance resulting from benefit payments or other sources may be applied to another account owed by the patient. This may not be revoked as to services provided during this hospitalization clinic visit, or corresponding course of diagnosis and treatment.
FINANCIAL AGREEMENT. I agree to pay promptly and fully all charges for services and supplies provided by SRMC, physicians and other health care providers, in accordance with their regular rates and terms. I hereby personally obligate the patient and myself, if signing as a spouse of the patient or as parent or legal guardian of a minor patient, to pay all such charges to the extent not covered by insurance . No extension or forbearance, attempt to obtain payment from insurance or other sources, or delay or lack of diligence in collecting such charges shall waive or release this personal financial. I understand that it is my responsibility to obtain any pre-admission approval required by my insurer, and to take all other steps to qualify for insurance coverage.
AUTOMATED TEXT APPOINTMENT REMINDERS. By signing below, the patient consents to the receipt of automated appointed reminders.
AUTHORIZATION for RELEASE of INFORMATION. By signing below, the patient authorizes SRMC to release all or any part of his or her medical records or such other information as may be necessary to process his or her claim for payment of benefits to insurance carriers and/or their representatives, his or her employer when services are related to a workers' compensation claim, the Social Security Administration or its intermediaries or carrier, and such other agencies, organizations, or individuals as necessary for a purpose related to benefit payment . By signing below, the patient authorizes SRMC to release all or part of his or her medical record from this visit to any physician or other health care provider (and their staff) who as necessary to aid in the continued care of the patient. If the patient does not want information sent, the patient should contact the Medical Records Department. The patient further understands that this consent applies to treatment yet to be provided. The patient acknowledges that such care will result in information being made a part of their medical record and that SRMC is under no obligation to consult further with the patient prior to disclosing such information pursuant to this authorization and their current insurance policy requirements for payment.
INDEPENDENT PROFESSIONAL CARE. I understand that some of the physicians and certain other practitioners providing services to the patient may be independent contractors and not employees or agents of SRMC, and that SRMC is not responsible for the acts or omissions of such persons. I understand that if I desire private duty nursing or other health care services beyond those services normally provided at the SRMC, I will be responsible for arranging and paying for such services, and I must obtain SRMC approval of such private arrangements.
BLOOD TESTS. As a condition of admission, but ONLY in the event of direct exposure with the patient's blood or bodily fluids by a health care worker, I understand that SRMC must evaluate whether the worker has been exposed to any infectious diseases, and may draw patient ’s blood for the purpose of performing, at SRMC’s expense, tests for infectious diseases such as the AIDS virus and hepatitis as SRMC deems necessary and appropriate for the protection of SRMC’s employees and staff. To preserve the patient ’s confidentiality, the results of such a test performed pursuant to this authorization will be disclosed only to those with a need to know .
NON-DISCRIMATORY. In accordance with Section 1557 of the Affordable Care Act, Sidney Regional Medical Center does not discriminate on the basis of race, color, religion, national origin, sex (including gender identity), sexual orientation, age, or disability.

This consent shall remain in effect until the listed patient is 19 years of age or until I provide written notification to no longer be the guarantor for the accounts of this patient.

I have read and agree to the terms and conditions of the Admission and Consent to Treatment.

Agree

Date of Consent (mm/dd/yyyy)

Name of Patient

Date of Birth (mm/dd/yyyy)

Name of Guarantor (if patient is a minor)

Date of Birth of Guarantor (mm/dd/yyyy)

Please press "Next" to continue to page 4.

Notice of Privacy Practices

Please click on and read the Notice of Privacy of Practices:

We are required by law to maintain the privacy of your medical information and to provide you with notice of our legal duties, privacy practices and your rights in regards to your medical information.

By signing the Notice of Privacy Practices you are simply acknowledging that we have given you the option to read the Privacy Notice

I have read and acknowledge the Notice of Privacy Practices

Agree

Date of acknowledgement of Notice of Privacy Practices (mm/dd/yyyy)

Please press "Next" to continue to page 5.

Advance Directive or Living Will

Advance Directive of Living Will- This is a document that addresses your medical wishes. If SRMC has one on file we would know what type of medical care you would want in the instance you could not speak for yourself. It addresses issues such as do no resuscitat, if you want to be on a monitor, or receive transfusions.

Please select the appropriate response

I do not have one or do not want one on file with SRMC

I have one and will bring a copy to SRMC

I have one on file at SRMC

I will complete one now

I will print and bring into SRMC at a later date

Please press "Next" to continue to page 6.

Patient Data Exchange

Common Well. SRMC and many other healthcare providers are exchanging patient data electronically rather than by fax or mnail using common well.

Why would I want my data shared? What is the benefit to me if I share my data?

If you visit another participating doctor, your doctor could access this information without any hassel to you receive relevant information related to your condition, which could help improve your care decisions.

If you go to a participating emergency room, the WR providers can see your health information from your participating providers, which could save time diagnosing you.

Also, if you had lab tests performed at one provider and then you visit another providerm that provider would have access to the test results from the first provider. This means that the tests might not have to be repeated, saving you time and money.

Who has access to this data?

Only staff that is directly involved in your care will access your medical information shared through the CommonWell service and it won't be shared with other care settings unless you enroll in the service.

Participating providers can be found at www.commonwellalliance.prg/providers

Please select the appropriate response below

I choose to participate in CommonWell

I do not want to participate in CommonWell and have completed the Refusal From below

NeHII is a state-wide, internet based, health information exchange. Using NeHII, participating providers and health insureres cam see certain health, demographic and payment information in each other's records. They can use this information for treatment and payment purposes. You can Opt out, get help understanding NeHII, and your rights by calling the NeHII help line at 866-978-1799 or visiting the NeHII website at www.connectnebraska.net.

I have read and understand the information about NeHII

Agree

Please press "Next" to continue to page 7.

Upload Important Documents

Each year SRMC needs an updated copy of your Drivers License

I have uploaded my current Drivers License within the last year

I will upload my Drivers License below

Please upload your Drivers License

Each year SRMC needs an updated copy of your Insurance Card(s)

I have uploaded my current insurance card(s) within the last year

I will upload my current insurance card(s) below

Please upload the front of your insurance card

Please upload your secondary insurance card (if applicable)

Do you have an order from a non-SRMC physician, please upload it here or bring it with you

You have complete the Pre Admit Online Registration Form, please continue to step 2 of the Pre Regstration process.

Thank you!

Welcome to SRMC
Required Regulatory Postings
Find A Provider
Services

Careers
Patient Portal
Patient Billing Tools
No Surprises Act
Health Center Foundation

Sidney Regional Medical Center

1000 Pole Creek Crossing
Sidney, NE 69162

(308) 254-5825 | info@sidneyrmc.com

eMail Newsletter Signup

Sign Up