Baxter Regional Medical Center
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(870) 508-1000
SERVICES & PROGRAMS | FIND A PHYSICIAN | RESOURCES & PATIENT EDUCATION
Childbirth Online Registration Form
Dear Patient:
Your doctor arranged for your testing/procedure at BRMC in Mountain Home, Arkansas. In order to better serve you, please complete and submit the following information on this form.
Please allow two business days for submitted information to be processed.
Thank you for your cooperation.

If you need help with filling out this form or prefer to pre-register by phone, please feel free to call us at 870-508-1970 - 7:00 a.m. - 4:30 p.m. Mon -Fri. We are closed Saturdays, Sundays and holidays.

* Asterisk indicates a required field.
Physician Information
Admitting Doctor's Name * Date of Service *
Primary Care Physician * Procedure *
  Diagnosis/Reason for Procedure *
 
Patient Information
First Name * Physical Address *
Middle Name City *
Last Name * State *
Email * Zip *
Due Date * Phone Number *
Date of Birth * Cell Phone Number
Social Security Number * Language
Birth State/County Religious Preference
Marital Status * Church Synagogue
Race *  
 
Employment Information
Employment Status Employer's Address
Employer's Name Employer's City
Occupation Employer's State
Work Phone Employer's Zip
Guarantor Information
Same as patient information
First Name * Mailing Address *
Middle Name City *
Last Name * State *
Date of Birth * Zip *
Social Security Number Phone Number *
  Cell Phone Number
 
Guarantor Employment Information
Same as patient information
Employment Status Employer's Address
Employer's Name Employer's City
Occupation Employer's State
Work Phone Employer's Zip
Emergency Contact Information
Same as patient information
First Name Address
Middle Name City
Last Name State
Relation Zip
Phone Number Cell Phone Number
Emergency Employment Information
Same as patient information
Employer's Name Work Phone
Occupation  
 
Primary Insurance Information
Insurance Company Name
Insurance Employer Name
Billing Address
City
State
Zip
Policy/Certificate/ID#
Group#
Insured's Date of Birth
Name of Insured
Relation to Insured
Insured Social Security #
Benefit/Eligibility Phone Number
Type of Insurance
Secondary Insurance Information
Insurance Company Name
Insurance Employer Name
Billing Address
City
State
Zip
Policy/Certificate/ID#
Group#
Insured's Date of Birth
Name of Insured
Relation to Insured
Insured Social Security #
Benefit/Eligibility Phone Number
Type of Insurance
Miscellaneous Information
Please bring your Doctors Order, Insurance Identification Card and a Picture ID with you at time of admission to prevent any delay. You may receive an e-mail or a representative may contact you if there is missing or incomplete information. If you have questions or concerns about hospital billing, we will be glad to refer to you to one of our Financial Counselors.
I have reviewed all information I have entered and it is correct to the best of my knowledge.
Hospice of the OzarkssuperDimension™ Navigation SystemBreast Imaging CenterBaxter Regional Medical CenterMobile 3D MammographyWomen's CenterBaxter Regional Hospital Foundation
624 Hospital Drive, Mountain Home, Arkansas 72653 • (870) 508-1000 • Physician's Referral Service: 1-800-695-DOCS (3627)
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