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In order to better serve you, we ask that you pre-register for your delivery date at least four weeks prior to your due date.

Upon receiving this form, we will call your insurance to verify coverage and verify that authorizations and referrals are in place. We will then inform you of any financial responsibilities you may have. Deductibles and copays are due at the time of service.

All scheduled C-sections require an appointment with a preadmit nurse at least 3 days before surgery. Please call Poudre Valley Hospital: 970.495.8700 for an appointment. Out of town patients may be able to do a phone interview.

• Most insurance plans require you add the newborn within 30 days of delivery in order for newborn to be covered.
• Self-insured plans do not always automatically cover the newborn for the first 30 days. Check with your employer for information.
• Notify us if the baby is covered by a different insurance plan then what the mother is covered by.
• If the baby stays longer then the mother, copays and deductibles are normally due on the baby for the delivery.

* Indicates required information
Today's Date 
First Name (Patient's Legal Name) * 
Middle Initial 
Last Name (Patient's Legal Name) * 
Maiden/Other Name 
Date of Birth (mm/dd/yyyy) * 
Social Security Number 
Email Address 
Marital Status 
Religious Preference 
Preferred language for discussing health care 
Are interpretive services or communication aids requested? 
If yes, please specify: 
Mailing Address * 
City * 
State * 
Zip Code * 
Home Address 1 (if different than Mailing Address) 
Home Address 2 
Zip Code 
Primary Phone * 
Other Phone 
Patient’s Employer 
Employer’s Address/Phone 
Primary Person to Notify (in case of an emergency) 
Secondary Person to Notify 
Primary Insurance Name (If you don't have insurance, please list Self Pay.) * 
Insurance Address/Phone # 
Subscriber/Policy Holder's Legal Name  
Patient's relationship to subscriber 
Subscriber's Date of Birth (mm/dd/yyyy) 
Policy/Unique ID Number 
Group Number if available (Not all insurance plans provide a group number.) 
Subscriber’s Employer 
Will the baby be covered under the same insurance as the mother? * 

If Other, please specify:

If no, please list insurance coverage for baby below (or secondary coverage if applicable). 
Baby’s Insurance Name 
Insurance Address 
Insurance Phone 
Date of Birth (mm/dd/yyyy) 
Policy # 
Group # 
Prenatal Care Provider (Doctor, Nurse Midwife, Nurse Practitioner) * 
Family Physician 
Expected Due Date (mm/dd/yyyy) *  (mm/dd/yyyy)
Authentication * 

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