Houston Methodist. Leading Medicine.
Houston Methodist. Leading Medicine

Email Forms Manager

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 privacy, all of our online forms are encrypted and stored in a secure location.
* Indicates required information
Patient's First Name & Middle Initial * 
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* 
Patient's Social Security Number (if none, enter 888-88-8888) * 
Patient's Gender * 
Type of Admission * 
Physician's Name * 
Office Contact Name 
Office Contact Phone Number 
Office Contact Fax Number 
Are You the PCP? 

Does This Procedure Require PCP Referral? 

Referral Number 
Requested/Service Date/Time 
Diagnosis/Chief Complaints * 
ICD 9 Code 
Procedure * 
CPT Code 
Type of Anesthesia 
Is An Implant Required For This Procedure? 

Name/Type of Implant Requested 
Special Instructions 
Is Patient Allergic to Latex? 
Is Patient Allergic to Iodine? 
Is Patient Pregnant? 

Billing Information 
Is the Patient the Guarantor? 

If yes, then proceed to insurance information 
If no, them fill Guarantor's Information 
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 
Insurance #1 
Insurance #1's Name 
Insurance #1 Type 
Insured's Name #1 
Insured's Date of Birth #1 
ID/Policy Number #1 
Is Insurance #1 a Group Policy 

Does Patient Have Insurance? 

Group Name #1 
Group Number #1 
Telephone Number We Should Call To Verify Benefits #1 
Precertification Phone Number #1 
Billing Address #1 
City, State, Zip Code #1 
Additional Information #1 
Insurance #2 
Insurance #2 Name 
Insurance #2 Type 
Insured's Name #2 
Insured's Date of Birth #2 
ID/Policy Number #2 
Is Insurance #2 a Group Policy 

Group Name #2 
Group Number #2 
Telephone Number We Should Call to Verify Benefits #2 
Precertification Phone Number #2 
Billing Address #2 
Additional Information #2 
City, State, Zip Code #2 
Worker's Compensation (if applicable) 
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 #3 
Authentication * 

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