COA Pre-Registration Form
	Please fill out the information below.
	Important Note: This Pre-registration form must be completed and submitted at least 24 hours in advance of your estimated arrival date and time.

* Indicates required information		Patient Information
	Has the patient ever been to Children's of Alabama? *	Yes No
	Legal Last Name *
	Legal First Name *
	Legal Middle Name
	Date of Birth *
	Address *
	City *
	State *	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY
	Zip Code *
	Primary Phone Number *
	Race *	American Indian or Alaskan Native Asian Black or African American Native Hawaiian Pacific Islander White Undertermined Patient Declined Information
	Gender *	Male Female
	Ethnicity *	Hispanic/Latino Non Hispanic or Latino

		Guarantor Information
	Is this person bringing the patient to their appointment? *	Yes No
	Legal Last Name *
	Legal First Name *
	Legal Middle Name
	Date of Birth *
	Address *
	City *
	State *	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY
	Zip Code *
	Phone Number *
	Gender *	Male Female
Would you like confirmation that you have been pre-registered?
	Email Address

		Insurance Information
	Primary Insurance Company *	Accordia National/Accordia National Alabama Medicaid/AL Mcaid Transplant Alabama Medicaid/Patient First Alabama Medicaid/PF Dental Alabama Youth Svs/Alabama Youth Svs Alternative Insur/Alternative Insur American Behavioral/American Behavioral American Med Secty/American Med Secty Amerihealth ADM/Amerihealth ADM BDCT/BDCT Beech Street PPO/Beech Street Behavioral Hlth Sys/Behavioral Hlth Sys Benefit Planners/Benefit Planners Blue Cross/ All Kids Blue Cross Blue Cross/BC Other Blue Cross/Blue Cross HMO Blue Cross/Blue Cross out of St Blue Cross/ Blue Cross PMD Blue Cross/Blue Cross PMD PEEHI Blue Cross/Blue Cross PMD SEIB Blue Cross/Generic Blue Cross Blue Cross/SCT Blue Cross Central Reserve Life/Central Reserve Life CHAMPVA/CHAMPVA Childrens Rehab Serv/Childrens Rehab Svs Choice Care/Choice Care Cigna/Boilmakers Cigna Cigna/Cigna Commercial Ins Misc/Commercial Ins Misc Coventry/Coventry HP Definity Health/Definity Health Delta Dental/Delta Dental Dept Industrial Rel/Dept Industrial Rel DHR/DHR First Health PPO/First Health Fortis/Fortis GEHA/GEHA Guardian Life/Guardian Life Health Choice PPO/Aetna Health choice PPO/Health Choice Healthscope PPO/Healthscope PPO Healthspring/Health Spring HealthStrategies/Healthstrategies Humana Mil TRICARE/Humana Mil TRICARE Integrated Hlth PPO/Integrated Health Kaiser Permanente/Kaiser Permanente Life Trac Network/Life Trac Network Mailhandlers CAN/Mailhandlers CAN MC Administrators/MC Administrators Medicare/Medicare A Medicare/Medicare B Medicare/Medicare Part B Dial Metropolitan Life/Metropolitan Life MHCA/ALL KIDS CBH ONLY Mississippi Medicaid/Mississippi Medicaid Mississippi Medicaid/MS MCaid Transplants Multiplan PPO/Multiplan PPO Mutual of Omaha/Mutual of Omaha NAHGA Claims Svcs/NAHGA Claims Svcs NovaNet/Nova Net OOS Medicaid/Medicaid Dental OOS Medicaid/SCTMeddicaid OptumHealth/OptumHealth PCPA/PCPA PHCS/PHCS Phifer Wire/Phifer Wire Possible Medicaid/Possible Medicaid Principal Mutual Lfe/Principal Mutual Lfe Research and Grant/Research and Grant Retail Wholesale/Retail Wholesale Shaw Industries/Shaw Industries Southland National/Southland National Southwire/Southwire Three Rivers PPO/Three Rivers PPO Unicare/Unicare United HealthCare/United HC MCare HMO United HealthCare/United HealthCare H United HealthCare/United HlthCare PPO Viva Health/Viva Wausau Life Insurance/Wausau Life Insurance
	Contract/Policy Number *
	Group Number
	Subscriber Name *
	Subscriber Date of Birth *
	Secondary Insurance Company	Accordia National/Accordia National Alabama Medicaid/AL Mcaid Transplant Alabama Medicaid/Patient First Alabama Medicaid/PF Dental Alabama Youth Svs/Alabama Youth Svs Alternative Insur/Alternative Insur American Behavioral/American Behavioral American Med Secty/American Med Secty Amerihealth ADM/Amerihealth ADM BDCT/BDCT Beech Street PPO/Beech Street Behavioral Hlth Sys/Behavioral Hlth Sys Benefit Planners/Benefit Planners Blue Cross/ All Kids Blue Cross Blue Cross/BC Other Blue Cross/Blue Cross HMO Blue Cross/Blue Cross out of St Blue Cross/ Blue Cross PMD Blue Cross/Blue Cross PMD PEEHI Blue Cross/Blue Cross PMD SEIB Blue Cross/Generic Blue Cross Blue Cross/SCT Blue Cross Central Reserve Life/Central Reserve Life CHAMPVA/CHAMPVA Childrens Rehab Serv/Childrens Rehab Svs Choice Care/Choice Care Cigna/Boilmakers Cigna Cigna/Cigna Commercial Ins Misc/Commercial Ins Misc Coventry/Coventry HP Definity Health/Definity Health Delta Dental/Delta Dental Dept Industrial Rel/Dept Industrial Rel DHR/DHR First Health PPO/First Health Fortis/Fortis GEHA/GEHA Guardian Life/Guardian Life Health Choice PPO/Aetna Health choice PPO/Health Choice Healthscope PPO/Healthscope PPO Healthspring/Health Spring HealthStrategies/Healthstrategies Humana Mil TRICARE/Humana Mil TRICARE Integrated Hlth PPO/Integrated Health Kaiser Permanente/Kaiser Permanente Life Trac Network/Life Trac Network Mailhandlers CAN/Mailhandlers CAN MC Administrators/MC Administrators Medicare/Medicare A Medicare/Medicare B Medicare/Medicare Part B Dial Metropolitan Life/Metropolitan Life MHCA/ALL KIDS CBH ONLY Mississippi Medicaid/Mississippi Medicaid Mississippi Medicaid/MS MCaid Transplants Multiplan PPO/Multiplan PPO Mutual of Omaha/Mutual of Omaha NAHGA Claims Svcs/NAHGA Claims Svcs NovaNet/Nova Net OOS Medicaid/Medicaid Dental OOS Medicaid/SCTMeddicaid OptumHealth/OptumHealth PCPA/PCPA PHCS/PHCS Phifer Wire/Phifer Wire Possible Medicaid/Possible Medicaid Principal Mutual Lfe/Principal Mutual Lfe Research and Grant/Research and Grant Retail Wholesale/Retail Wholesale Shaw Industries/Shaw Industries Southland National/Southland National Southwire/Southwire Three Rivers PPO/Three Rivers PPO Unicare/Unicare United HealthCare/United HC MCare HMO United HealthCare/United HealthCare H United HealthCare/United HlthCare PPO Viva Health/Viva Wausau Life Insurance/Wausau Life Insurance
	Contract/Policy Number
	Group Number
	Subscriber Name
	Subscriber Date of Birth

		Emergency Contact
		This should be someone outside of the home
	Name *
	Phone Number *
	Relationship to Patient *

		Appointment Information
	Which provider is the patient seeing? *
	When is the appointment? (mm/dd/yy) *
	Where is the apppointment? *	Main Campus Children's South Children's on 3rd Park Place
	Do you need an interpreter? *	Yes No
	Patient Preferred Language *	Arabic/Farsi Bengali/Bangla Catalan Chinese Czech English French German Greek Hebrew Hindi Italian Japanese Korean Lithuanian Persian Polish Portuguese Quechua Russian Spanish Swedish Vietnamese Sign Language Unknown Other
		If Other, specify:

		Referring Physician
	Last Name
	First Name
	City
	State	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY

		Primary Care Physician
	Last Name
	First Name
	City
	State	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY

	Pre-registration Disclaimer (Must Read)
	Email communication on the internet may NOT be secure. Children's of Alabama (Children's) makes no warranty, express or implied, regarding the security of any information to be submitted to it through web site. There is a risk that confidential information submitted by you to Children's through this web site, including a completed Pre-registration Form, may be intercepted illegally by a third party. If you elect to electronically submit a completed Pre-registration Form, or any other information, to Children's through this web site, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission or from any errors or omissions in the data you provide. You agree to release and hold Children's (and its employees, medical staff, agents, and/or representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of any information submitted electronically by you through this web site and from any errors or omissions in the data you provide. Additionally, the provision of any information to Children's by you through this web site, including a completed Pre-registration Form, does not create or constitute any relationship between you and Children's (and its employees, medical staff, agents and/or representatives) to which any privilege may attach. By voluntarily submitting my information, I agree to this pre-registration disclaimer.
	Before clicking the submit button, please review your information. You will not have the opportunity to edit it.