Complete Registration

Allina Health preregistration form for Abbott Northwestern Hospital, Mother Baby Center (Minneapolis), WestHealth (Plymouth)

* Location

* Arrival Date for services

We encourage all patients to preregister. This way, your paperwork can be prepared before you arrive and we can expedite your check-in process.

To preregister online simply fill 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.

Bring your completed health care directive. The document gives written instructions about your medical care should a health care crisis occur. Learn about completing a health care directive.

If you have questions or would like to preregister by telephone, call 612-262-7878 or 1-888-660-0014. If your appointment is less than five days away, call to preregister.

Please note: Online preregistrations are entered Monday through Friday, 8 a.m. to 4:30 p.m.

We encourage all patients to preregister. This way, your paperwork can be prepared before you arrive and we can expedite your check-in process.

To preregister online simply fill 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.

Bring your completed health care directive. The document gives written instructions about your medical care should a health care crisis occur. Learn about completing a health care directive.

If you have questions or would like to preregister by telephone, call 612-262-7878 or 1-888-660-0014. If your appointment is less than five days away, call to preregister.

Please note: Online preregistrations are entered Monday through Friday, 8 a.m. to 4:30 p.m.

Starting January 1, 2022, District One Hospital will become Allina Health Faribault Medical Center. The new name represents our commitment to delivering the best possible care to the Faribault community.

We encourage all patients to preregister. This way, your paperwork can be prepared before you arrive and we can expedite your check-in process.

To preregister online simply fill 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.

Bring your completed health care directive. The document gives written instructions about your medical care should a health care crisis occur. Learn about completing a health care directive.

If you have questions or would like to preregister by telephone, call 612-262-7878 or 1-888-660-0014. If your appointment is less than five days away, call to preregister.

Please note: Online preregistrations are entered Monday through Friday, 8 a.m. to 4:30 p.m.

We encourage all patients to preregister. This way, your paperwork can be prepared before you arrive and we can expedite your check-in process.

To preregister online simply fill 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.

Bring your completed health care directive. The document gives written instructions about your medical care should a health care crisis occur. Learn about completing a health care directive.

If you have questions or would like to preregister by telephone, call 612-262-7878 or 1-888-660-0014. If your appointment is less than five days away, call to preregister.

Please note: Online preregistrations are entered Monday through Friday, 8 a.m. to 4:30 p.m.

We encourage all patients to preregister. This way, your paperwork can be prepared before you arrive and we can expedite your check-in process.

To preregister online simply fill 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.

Bring your completed health care directive. The document gives written instructions about your medical care should a health care crisis occur. Learn about completing a health care directive.

If you have questions or would like to preregister by telephone, call 612-262-7878 or 1-888-660-0014. If your appointment is less than five days away, call to preregister.

Please note: Online preregistrations are entered Monday through Friday, 8 a.m. to 4:30 p.m.

We encourage all patients to preregister. This way, your paperwork can be prepared before you arrive and we can expedite your check-in process.

To preregister online simply fill 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.

Bring your completed health care directive. The document gives written instructions about your medical care should a health care crisis occur. Learn about completing a health care directive.

If you have questions or would like to preregister by telephone, call 612-262-7878 or 1-888-660-0014. If your appointment is less than five days away, call to preregister.

Please note: Online preregistrations are entered Monday through Friday, 8 a.m. to 4:30 p.m.

We encourage all patients to preregister. This way, your paperwork can be prepared before you arrive and we can expedite your check-in process.

To preregister online simply fill 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.

Bring your completed health care directive. The document gives written instructions about your medical care should a health care crisis occur. Learn about completing a health care directive.

If you have questions or would like to preregister by telephone, call 612-262-7878 or 1-888-660-0014. If your appointment is less than five days away, call to preregister.

Please note: Online preregistrations are entered Monday through Friday, 8 a.m. to 4:30 p.m.

We encourage all patients to preregister. This way, your paperwork can be prepared before you arrive and we can expedite your check-in process.

To preregister online simply fill 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.

Bring your completed health care directive. The document gives written instructions about your medical care should a health care crisis occur. Learn about completing a health care directive.

If you have questions or would like to preregister by telephone, call 612-262-7878 or 1-888-660-0014. If your appointment is less than five days away, call to preregister.

Please note: Online preregistrations are entered Monday through Friday, 8 a.m. to 4:30 p.m.

OB Patients

Little Saints Photography session (optional)

This is the first step to having long-lasting memories captured by Little Saints Photography. A portion of this purchase benefits the Saints Foundation and directly impacts the Family Birth Place at St. Francis Regional Medical Center. Review packages & reserve a session.

* What type of care will you be receiving

Type of Care Other

* Do you need an interpreter?

If yes, Language spoken

For what procedure or test are you scheduled?

Expected Due Date

Baby's last name

Name of baby's doctor

Baby's insurance

Policy holder's full name

Subscriber's Date of Birth

Group Name

Group Number

Insurance Name

Employer Name

Primary care provider/Clinic name

None (Primary Care/Provider)

Admitting/Referring/Ordering Physician Name

If family or friends call us, do you want them to know you are a patient here?

Patient information

* Gender

Social Security number (SSN)

Decline

* Birth Date

* First Name

* Middle

* Last Name

Preferred name or nickname

List any other names you have been known at Allina Health

* Street Address

* City

* State

* Zip

* Primary Phone Type

* Primary Phone

Secondary Phone Type

Secondary Phone

MyChart Enrollment

In order to enroll in MyChart/MyAccount, you must provide an email.

MyChart is the secure way to manager your health care online. View your discharge instructions, access portions of your health records, plus other features. Learn more here....

Email Address

Decline

* Marital Status

Religion

Place of Worship

* Country of origin/birth place

* Are you legally blind ?

* Do you need assistance for hearing?

* In which language do you to prefer to discuss your health care

Aside from your preferred language, are there any additional languages you speak ?

* Are you also able to read and write in all of the languages that you speak

* Ethnic Group

* Race

* Employment Status

Occupation

Employer Name

Street Address

City

State

Zip

Emergency contacts

Primary Contact Name

Relationship to patient

Relationship Other

Phone Type

Phone Number

Secondary Contact Name

Relationship to patient

Relationship Other

Phone Type

Phone Number

Guarantor information

* Who is your guarantor? (person responsible to pay your medical bill)

If Other, please list

Name

Birth Date

Social Security number (SSN)

Decline

Street Address

City

State

Zip

Phone Type

Phone Number

Employment Status

Insurance information

* Do you have insurance?

Primary insurance information

Insurance Name

Street Address

City

State

Zip

Phone Number

Group Number

Identification Number

Relationship to patient

Subscriber's name

Subscriber's Birth Date

Employer Name

Street Address

City

State

Zip

Employment Occupation

Secondary insurance information

Insurance Name

Street Address

City

State

Zip

Phone Number

Group Number

Identification Number

Relationship to patient

Subscriber's Name

Subscriber's Birth Date

Employer Name

Street Address

City

State

Zip

Employment Occupation

Tertiary / Third insurance information

Insurance Name

Street Address

City

State

Zip

Phone Number

Group Number

Identification Number

Relationship to patient

Subscriber's Name

Subscriber's Birth Date

Employer Name

Employer Street Address

City

State

Zip

Employment Occupation

Medicare information

* Do you have Medicare?

Medicare ID number

Part A Effective date

Part B Effective date

Patient's retirement date

Spouse's retirement date

Entitlement base on

Do you receive Black Lung Medical Benefits

Has the Department of Veterans Affairs agreed to pay for services at this facility

Department of Veterans Affairs

Will your services be paid for by a government program or grant other than Medicare/Medicaid

If yes, explain

Accident/injury information

Is this visit due to an accident or injury

Type of accident or injury

Motor Vehicle type of accident or injury, please provide the following information:

Insurance company name

Policy Number

Claim Number

Adjusters Name

Phone Number

Work type of accident or injury, please provide the following information:

Employer Name

Street Address

City

State

Zip

Insurance company's Phone number

Third party liability or Other type of accident or injury, please provide the following information

Contact information / home

Other accident or injury

Explain

Date of accident or injury

Time of accident or injury (if known)

State where accident or injury occurred

Briefly explain what happened and what body part was injured