Houston Methodist. Leading Medicine.
Houston Methodist. Leading Medicine

Scheduling and Registration Procedure Scheduled by Doctor

Thank you for registering online for your patient's procedure(s) at The Methodist Hospital. Please complete this form at least three business days prior to the scheduled procedure date. After completion, you will receive a response via fax or telephone within 24 hours, excluding weekends or holidays.

To protect your privacy, all of our online forms are encrypted and stored in a secure location. Please note that while our forms are secure, any communication via e-mail may not be secure, so please consider that when selecting a way for us to contact you. If you select phone or e-mail as your preferred method of contact, every effort will be made to return your request by the next business day. A response to your request via postal mail may take up to 10 business days to receive.
* Indicates required information
Patient's First Name * 
Middle Initial 
Patient's Last Name * 
Patient's Address 1 * 
Patient's Address 2 
City * 
State * 
Zip Code * 
Country * 
Work Phone Number 
Home Phone Number * 
E-mail Address * 
Date Of Birth * 
By selecting this box and the "Submit" button, I agree to the Disclaimer and Privacy Policy* 
Is this a medical emergency? * 

Patient's Social Security Number (if no SSN, enter 888-88-8888) * 
Patient's Gender * 

Type of Admission * 

Physician's Name * 
Physician Office E-mail Address * 
Office Contact Name 
Office Contact Phone Number 
Office Contact Fax Number 
Requested/Service Date/Time 
Diagnosis/Chief Complaints * 
ICD 9 Code 
Procedure or Possible Treatment * 
CPT Code 
Billing Information 
Is the Patient the Guarantor? * 

Guarantor's Name 
Guarantor's Date of Birth 
Guarantor's SSN 
Guarantor's Billing Address 
Guarantor's Billing City, State, Zip 
Guarantor's Phone Number 
Is Patient Employed? 

Employer 
Employer's Address 
Employer's City, State, Zip Code 
Employer's Country 
Employer's Phone Number 
Is Patient's Insurance Through Employer? 

What insurance does the patient have? 
Does Insurance know the patient is having this procedure 

Insurance 
Insurance Name 
Insurance Type 
Insured's Name 
Insured's Date of Birth 
ID/Policy Number 
Is Insurance a Group Policy 

Group Name 
Group Number 
Benefits Phone Number 
Precertification Phone Number 
Billing Address 
City, State, Zip Code 
Additional Information 
Insurance #2 
Insurance Name 
Insurance Type 
Insured's Name 
Insured's Date of Birth 
Is Insurance a Group Policy 

Group Number 
Group Name 
Benefits Phone Number 
Precertification Phone Number 
Billing Address 
City, State, Zip Code 
Additional Information 
Date of Accident 
Employer at Time of Accident 
State Accident Occurred 
Country Accident Occurred 
Adjuster's Name 
Adjuster's Phone Number 
Adjuster's Billing Address 
Adjuster's City, State, Zip Code 
Additional Information 
Name on Medicare Card: 
Medicare Number: 
Part A Eff Date: 
Part B Eff Date 
Recipient Name: 
Recipient Number: 
Case Name 
Case Number 
Does Patient Have additional insurance? 

Authentication * 

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