Skip to main content
You are here: Services > Cambridge Medical Center    
 

Preregister for your visit to Cambridge Medical Center

At Cambridge Medical Center, we encourage all hospital obstetrical or surgical patients to preregister. This way, your paperwork can be prepared before you arrive and we can expedite your check-in process.

And now, you can preregister online for a test or procedure scheduled at Cambridge Medical Center by filling out the form below.

  • Make sure all required fields (*) are filled in.
  • If a required field does not apply to you, type in "NA" or "Not Applicable."
  • Fill in as many fields as possible so we can best prepare your registration.

Please call your insurance company to inform them of your upcoming delivery or procedure. Many insurance companies require pre-authorization or they will deny coverage. You will also need to call them after your delivery if you wish to add the baby to your policy.

If you have questions or would like to preregister by telephone, call registration at (763)688-7732.

Please Note: Online preregistrations are entered Monday-Friday, 8 a.m. to 4:30 p.m. Please preregister at least one full business day before your appointment. If your appointment is less than one full business day away, preregister by phone with the registration at (763)688-7732.

* indicates required field

* What date will you be arriving for services? Month Day Year (or due date)  
  Personal Physician or Family Physician Name: Last
First
 
* What procedure/test are you having done?  
 
Patient Information
  Legal Name
*    Last:  
*    First:  
     Middle:  
  Social Security Number: - -  
  Marital Status:
 
* Sex:
  Race: (Required for Government reporting and medical research)
 
     Country of origin:  
* Date of Birth Month Day Year  
Mailing Address
* Street:  
* City:  
*State:  
* Zip:  
  County:  
* Phone Number:  
* Employment Status:
 
  Retirement Date:  
  Employer:  
  Occupation  
  Work Phone:  
  Employer Address [City , State, Zip]:  
 
Guarantor Information
[Person responsible for the bill. If the patient is the guarantor skip this section and go to Spouse Information]
Relation to Patient:  
Guarantor Name:
     Last:  
     First:  
     Middle:  
  Sex:  
  Date of Birth: Month Day Year  
  Social Security Number:  
  Marital Status:
 
  Guarantor Mailing Address  
  Street:  
  City:  
  State:  
  Zip:  
  County:  
  Employment Status:
 
  Employer:  
  Work Phone:  
  Employer Address [City , State, Zip]:  
    
Spouse Information
  Spouse Name:  
     Last:  
    First:  
    Middle:  
 Date of Birth: Month Day Year  
 Social Security Number:  
 Employment Status:
 
  Employer:  
  Work Phone:  
 Employer Address [City , State, Zip]:  
    
Emergency Contact Information (Other than listed above)
  Emergency Contact Name:
   Last:
First:
 
  Relation to Patient:  
 Day Phone:  
 Evening Phone:  
 
Accident Information
[To be filled out if this visit/admission is the result of an accident]
 Type of Accident:
 
  Date of Accident: Month Day Year  
  Place of Accident/Injury:  
  Body Part Injured:  
  Nature of Accident:  
  Claims Address:  
  Claim Number:  
  Agent/Claims Adjuster:  
  Claim Phone:  
 
Insurance Information - Primary
  Name of Insurance Company:  
  Policy Holder Name:  
  Relationship to Patient:  
  Group/Account Number:  
  Policy/ID Number/Claim Number:  
 
Insurance Information
  Do you have Medicare:  
  Effective Dates: Part A
Part B
 
  Are you entitled to Medicare based on:  
  Do you receive black lung medical benefits?  
  Will your services be paid by government program other than Medicare/Medicaid?  
        If yes, please
     explain
 
 
Secondary Insurance Information
  Name of Insurance Company:  
  Policy Holder Name:  
  Relationship to Patient:  
  Group/Account Number:
  Policy/ID Number:  
  Eligibility /Benefit /Customer Service Number:  
  Insurance Company Address:  
  Additional Information:  


This site uses a secure server (SSL) to encrypt all of your personal information. We use strong security measures to protect and prevent the loss of your information.