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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.

C-Section Deliveries
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.

IMPORTANT INSURANCE REMINDERS
• 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  (mm/dd/yyyy)
First Name (Patient's Legal Name) * 
Last Name (Patient's Legal Name) * 
Maiden/Other Name  
Date of Birth (mm/dd/yyyy) * 
Social Security Number 
Email Address 
Marital Status 
Race 
Ethnicity 
Religious Preference 
Preferred language for discussing health care: 
Are interpretive services or communication aids requested? 
If yes, please specify: 
Mailing Address 1 * 
Mailing Address 2 
City * 
State * 
Zip Code * 
Home Address 1 (if different from Mailing Address) 
Home Address 2 
City 
State 
Zip Code 
Primary Phone * 
Other Phone 
Patient’s Employer (or parent/guardian if patient under 18) 
Employer’s Address/Phone 
Primary Person to Notify (in case of an emergency) 
Relationship 
Address 
Phone 
Secondary Person to Notify 
Relationship 
Address 
Phone 
Primary Insurance Name * 
Insurance Address/Phone # 
Subscriber/Policy Holder 
Date of Birth (mm/dd/yyyy) 
Policy # 
Group # 
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). 
Secondary or Baby’s Insurance Name 
Insurance Address/Phone 
Subscriber 
Subscriber 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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Awards and Recognition


University of Colorado Health employees dedicate themselves to providing patients and other customers with world-class care and service. Outside organizations recognize that, calling University of Colorado Health's hospitals some of the best in Colorado and even the best in the nation. Some of those accolades are listed below:

 




Contact

University of Colorado Health
Fort Collins, Colorado
970.495.7000
PVHS@pvhs.org

 

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