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Preregister for your visit to Cambridge Medical Center

At Cambridge Medical Center, we encourage all hospital obstetrical or surgical patients to preregister. This way, your paperwork can be prepared before you arrive and we can expedite your check-in process.

And now, you can preregister online for a test or procedure scheduled at Cambridge Medical Center by filling 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.

Please call your insurance company to inform them of your upcoming delivery or procedure. Many insurance companies require pre-authorization or they will deny coverage. You will also need to call them after your delivery if you wish to add the baby to your policy.

If you have questions or would like to preregister by telephone, call registration at (763)689-7732 or (763)689-7731.

Please Note: Online preregistrations are entered Monday-Friday, 8 a.m. to 4:30 p.m. Please preregister at least one full business day before your appointment. If your appointment is less than one full business day away, preregister by phone with the registration at (763)689-7732 or (763)689-7731.

* indicates required field
 
* Department  
  What date will you be arriving for services? Month Day Year (or due date)  
  Personal Physician or Family Physician Name Last
First 		 
* What procedure/test are you having done?  
 
Patient Information
  Legal Name
*    Last  
*    First  
     Middle Initial  
  Social Security Number - -  
  Marital Status  
* Sex Male Female
  Race (Required for Government reporting and medical research) African American Asian Hispanic
American Indian Caucasian Other		  
* Date of Birth Month Day Year  
Mailing Address
* Street  
* City  
*State  
* Zip  
  County  
* Day Phone  
* Evening Phone  
* Employment Status Full-Time Not Employed Student
Part-Time Self-Employed Retired		  
  Retirement Date  
  Employer  
  Occupation  
  Work Phone  
  Employer Address [City , State, Zip]  
 
Guarantor Information
[Person responsible for the bill. If the patient is the guarantor skip this section and go to Spouse Information]
Relation to Patient  
Guarantor Name
     Last  
     First  
     Middle Initial  
  Sex Male Female  
  Date of Birth Month Day Year  
  Social Security Number  
  Marital Status Single Widowed Separated
Married Divorced Life Partner		  
  Guarantor Mailing Address Yes  
  Street  
  City  
  State  
  Zip  
  County  
  Employment Status Full-Time Not Employed Student
Part-Time Self-Employed Retired		  
  Guarantor's Retirement Date Month Day Year  
  Occupation  
  Work Phone  
  Employer Address [City , State, Zip]  
    
  Spouse Information If spouse & guarantor are the same check here and skip
  Spouse Name  
     Last  
    First  
    Middle Initial  
 Date of Birth Month Day Year  
 Social Security Number  
 Employment Status Full Time Not Employed Retired
Part Time Self Employed Student		  
 Occupation  
  Employer  
  Work Phone  
 Employer Address [City , State, Zip]  
    
Emergency Contact Information (Other than listed above)
 Emergency Contact Name Last
First 		 
  Relation to Patient  
 Day Phone  
 Evening Phone  
 
Accident Information
[To be filled out if this visit/admission is the result of an accident]
 Type of Accident Work Related Crime Victim
Auto Accident Other		  
  Date of Accident: Month Day Year  
  Location of Accident/Injury  
 
Describe Accident 		 
 
Insurance Information
  Medicaid Patients  
  Do you have Medicaid? Yes No  
  Medicaid number  
  Do you have Medicare Yes No  
  Medicare Claim Number  
  Effective Dates Part A
Part B 		 
  Are you entitled to Medicare based on Age Disability End Stage Renal Disease  
  Do you receive black lung medical benefits? Yes No  
  Will your services be paid by government program other than Medicare/Medicaid? Yes No  
        If yes, please
     explain 		 
 
  Insurance Information - Primary
  Name of Insurance Company  
  Policy Holder Name  
  Relationship to Patient  
  Group/Account Number  
  Policy/ID Number  
  Eligibility/Benefits/Customer Service Phone Number  
  Insurance Company Address  
 
 Secondary Insurance Information
  Name of Insurance Company  
  Policy Holder Name  
  Relationship to Patient  
  Group/Account Number
  Policy/ID Number  
  Eligibility /Benefit /Customer Service Phone Number  
  Insurance Company Address  
 
Other Information:
  Additional Information  
  Are you allergic to any medications? Yes No  
  Do you want the hospital to let people know that you are a patient here if friends call? Yes No  
  What name would you like the staff to call you?  

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