Pre-Registration Form

Welcome to Memorial Hospital and Health Care Center's pre-registration site! We are happy you have chosen us for your health care needs and look forward to serving you.

This form must be completed 24 hours prior to your scheduled appointment date.

Pre-registration is a function performed within Patient Registration at Memorial Hospital and Health Care Center. Our department is open 24 hours a day, so please contact us if you need assistance with completing this form. Between 5:00 a.m. and 8:00 p.m., you may call us at 812-996-5777. Between 8:00 p.m. and 5:00 a.m., please contact us at 812-996-5711 if you need our assistance.

Upon your arrival at Patient Registration, we will obtain all necessary signatures and scan your insurance card(s). We will need to review your insurance card(s) to verify coverage and to determine if pre-certification is required. A photo ID is also needed to verify your identity. In addition, if you have Medicare insurance coverage, we will need to complete the Medicare Secondary Payor (MSP) Questionnaire.

Thank you for choosing Memorial Hospital and Health Care Center!


Confirm Browser Compatibility

You are being directed to a secure MHHCC page to complete this transaction.

Specific browser versions are needed to process these secure forms. Recommended browsers are Chrome, Firefox, & IE v11 or above.

If your browser does not meet minimum requirements, please call our customer service line at 812-996-0651 for assistance.


Continue Cancel