How do I register?

How do I register?
The benefits of early registration are:
• Minimal paperwork upon admission
• Option to handle financial matters in advance
• Express discharge
1st Step: Pre-Registering
There are several ways to pre-register at Texas Children’s
Pavilion for Women:
In person: Visit the Pavilion for Women Admissions area
located at: Pavilion for Women – 3rd Floor
Online:
Visit our website at women.texaschildrens.org/prereg
Fax:
Fax completed pre-registration form to 832-825-9404
Attn: Pre-registration services
U.S. Mail: Mail completed pre-registration form to:
Texas Children’s Pavilion for Women
Admissions – 3rd Floor, P375
6651 Main Street
Houston, Texas 77030
Attn: Pre-registration Services
2nd Step: Completing Consent Forms
Signing consent forms for your upcoming delivery is required
for your admission. Patients that pre-register in person will be
able to sign their forms at the time of pre-registration. All others
are asked to visit the Admissions Department to sign required
forms. Please visit the Admissions office at:
Texas Children’s Pavilion for Women
6651 Main Street
Admissions – 3rd Floor
Houston, Texas 77030
3rd Step: Understanding Your Bill
Insured patients – We will gladly bill your insurance as a courtesy.
Please know that you will be responsible for payment of the
applicable hospital deductible, co-payments, co-insurance and
non-covered fees as determined by your insurance plan. To
inquire about your patient responsibilities, please contact the
Admissions Department at 832-826-3300.
Private pay patients – To request an estimate, please contact
our Admissions Department at 832-826-3300 to speak with
one of our financial counselors.
International patients – International patients should contact
the International Services Department at 832-824-1138. The
International Patient Services Team will be able to assist you
with the coordination of clinical and financial matters.
Additional Information
Suites and amenities packages – Call Guest Services for
information at 832-826-STAR (7827). Suites and amenities are
not covered by insurance, and discounts are not available for
employees of Texas Children’s Hospital. Suites are based on
availability and may not be reserved in advance.
Tours and educational classes – Call 832-825-3276 for information
about tours and educational classes.
It is our goal to make your visit a pleasant and enjoyable
experience for you and your family. If at any time you have
questions or need additional assistance, please do not hesitate
to contact the Admissions Department at 832-826-3300. Thank
you for choosing Texas Children’s Pavilion for Women to serve
you during this important event in your life.
© 2013 Texas Children’s Hospital. All rights reserved. PFW425_061013
It’s almost time for your delivery. To help you prepare, lessen
your stress and make your experience more pleasurable,
we ask that you please register with us by your 28th week
of pregnancy.
Hospital Admissions Pre Registraon Form
Fax: 832-825-9404
PATIENT INFORMATION
Last Name
First Name
Middle Name
Paent Language
Marital Status
Single
Married
Divorced
Separated
Widowed
Social Security Number (SSN) Home Phone
Date of Birth (DOB)
Ethnicity/Race
Translaon Needed:
Street Address
Yes
No
City
ZIP Code
State
Employer’s Address
City
Cell Phone
Employment Status
Unemployed
Full-me
Part-me
Full-me student
Part-me student
Email Address (Required if you would like to receive an
email confirmaon)
Employer
Occupaon
Religion
State
Work Phone
ZIP Code
CLINICAL INFORMATION
Visit related to
C-Secon
Vaginal Delivery
Surgery
Please check if applicable
Adopon
Surrogacy
Expected Due Date
OB/GYN Physician
Address
Phone Number
Pediatrician
Address
Phone Number
Primary Care Physician
Address
Phone Number
INSURANCE INFORMATION
Please Check Appropriate Box, is Paent
Paent’s Relaonship to Subscriber
Subscriber’s Name
Policy/Member Number
Provider Services Number
Self Pay
Self
Insured
Spouse
Child
Subscriber’s SSN
Policy/Member Number
Occupaon
Provider Services Number
Group Number
Occupaon
Specify:
Name of Primary Insurance
Member Services Phone Number
Claims Address
Group Number
Subscriber’s SSN
Other
Subscriber’s DOB
Employer
If secondary insurance is applicable, paent’s relaonship to subscriber
Subscriber’s Name
If insured, please complete the insurance
secon below.
Internaonal Paent
Self
Work Phone
Spouse
Subscriber’s DOB
Child
Other Specify:
Name of secondary insurance
Member Services Phone Number
Claims Address
Employer
Work Phone
Which insurance/policy will newborn baby be added to?
EMERGENCY CONTACT
Name
Relaonship to Paent
Emergency Contact Number
The above informaon is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially
responsible for any balance. I also authorize Texas Children’s Hospital and my insurance company to release any informaon required to process my claims.
Paent/Guardian Signature
Please complete the form in its enrety. Incomplete forms will not be processed.
Date