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If you are in your second trimester of pregnancy and you expect to give birth at Yale-New Haven Hospital, we invite you to submit preregistration material via the secure form below. If you prefer to submit your information via the mail, or if you have questions about filling out the form below, call Admitting at (203) 688-3331.

Maternity PreAdmission Form
Yale-New Haven Hospital
The information you provide on this form is submitted to Admitting and will be used to begin the pre-registration process for a maternity admission at Yale-New Haven Hospital. This information is treated as confidential.

Required fields are marked with *.
Section 1. Patient Information
Were you born at or have you ever been treated at Yale-New Haven Hospital? Yes No
If YES, do you know your 7 digit Medical Record number?
Under which name were you treated?
Last name     First name      Middle Initial  
 
Last name     First name       Middle Initial 
Address  
City      State      Zip  
Phone  ( ) - *Birthdate (MM/DD/YYYY)
Social Security Number - -
Marital Status  Ethnic Status 
Preferred Language
Religious Preference
Do you want your clergy to visit you while you are in the Hospital? Yes    No
If yes, please indicate place of worship
 
*When are you due to deliver?
OB Physician Last name      First name  
Primary Care Physician  
 
Patient Employer
Address  
City       State      Zip 
Phone ( ) - Ext.
Employment Status
Dept.   Occupation
If you are under age 18, please provide the following information. Otherwise SKIP to the next section
Parent/Guardian Information
Last name      First name  
Address
City    State      Zip 
Phone ( ) - Ext.
Birthdate (MM/DD/YYYY)
Social Security Number - -
Parent/Guardian Employer
Address  
City       State     Zip  
Phone ( ) - Ext.
Employment Status
Dept.   Occupation
Section 2. Nearest Legal Relative
Last name      First name       Middle Initial  
Address  
City       State       Zip 
Relationship
Phone ( ) - Ext.
In the event of an emergency, would you like us to notify this person? Yes      No
Additional Contact
Last name      First name       Middle Initial
Address 
City        State      Zip 
Relationship
Phone ( ) - Ext.
In the event of an emergency, would you like us to notify this person? Yes No
Section 3. Patient Insurance Information
In order to make sure we properly bill your insurance company, it is important to fill out the following insurance information correctly.
Precertification Explanation - If required, you must obtain pre-approval for your hospital admission through your insurance company prior to admission. Failure to do this may result in a penalty against your benefits. To help you complete this section you may want to refer to your insurance card.
Has Pre-Certification
been completed? 		Yes No Authorization
number
Name of Primary Insurance Company
Address  
City       State      Zip  
Group Number   Policy/Subscriber Number
Insurance Phone Number ( )  -    Ext.
Are you the subscriber? (A subscriber is the person who carries the insurance policy) Yes (if yes, SKIP to Section 3a)
No
If No, what is your relationship to the subscriber?
Subscriber Information
Last name      First name      Middle Initial 
Sex Male     Female
Birthdate (MM/DD/YYYY)
Social Security Number - -
Address  
City       State        Zip  
Phone ( ) -     Ext.
Subscriber Employer
Address  
City       State        Zip  
Phone () - Ext.
Employment Status
Occupation
Section 3a)
Are you Covered by any other health insurance? Yes
No (if no, SKIP to Section 4.)
If Yes, complete the following:
Precertification Explanation - If required, you must obtain pre-approval for your hospital admission through your insurance company prior to admission. Failure to do this may result in a penalty against your benefits. To help you complete this section you may want to refer to your insurance card.
Has Pre-Certification
been completed? 		Yes No Authorization
number
Name of Secondary Insurance Company
Address  
City       State     Zip  
Group Number  Policy/Subscriber Number
Insurance Phone Number ( ) -   Ext.
Are you the subscriber? Yes (if yes, SKIP to Section 4.)
No
If No, complete the following:
What is your relationship to the subscriber?
Subscriber Information
Last name      First name     Middle Initial  
Sex Male      Female
Birthdate (MM/DD/YYYY)
Social Security Number - -
Address  
City       State       Zip 
Phone ( ) -    Ext.
Subscriber Employer
Address  
City       State       Zip  
Phone ( ) -   Ext.
Employment Status
Occupation
Section 4: Hearing-Impairment
All hospitals in Connecticut must provide effective communication with people who are deaf and hard of hearing. It is the policy of Yale-New Haven Hospital to provide special equipment and services, including interpretation services, free of charge to patients (and their companions) who are deaf or hard of hearing, as appropriate for the delivery of medical care.
Are you deaf or hearing impaired? Yes      No
If yes, what is your preferred method of communication?
If yes, what other assistance do you need?
Is your companion deaf or hearing impaired? Yes      No
If yes, what is their preferred method of communication?
If yes, what other assistance do they need?
Does the Yale-New Haven Hospital have your permission to contact you via E-mail? Yes      No
If YES, Please provide your E-mail address.
We look forward to working with you to assure a pleasant admission process. Please contact us at (203) 688-3331 should you have any additional questions.
Please print this form now if you would like to keep a copy for your records.
 
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Last revised: September 14, 2006 (dh)