Good Sam San Jose Now Offers Online Pre-Registration
Who can Pre-Register Online?
- Patients with a procedure or surgery already scheduled
- OB Patients who would like to pre-register for labor and delivery
- Patients who need to request a screening Mammography appointment
How to Pre-Register Online
- Complete the 10-20 minute Online Pre-Registration and Mammogram Scheduling forms at least two business days prior to your scheduled appointment.
- For privacy reasons, if you leave your computer idle for more than 20 minutes, your form will not be saved and you will have to begin again.
- Check-in with our registration staff on the date of your scheduled service to complete the registration process. Please be advised that you will sign all consent forms during your visit.
Before you begin, be sure you have all of the items listed below on hand:
- Social Security Number
- Name of ordering physician
- Date of your scheduled procedure
- All insurance card(s) information
- Employer information
Prefer to register over the phone or in person?
We want your registration process to go as smoothly as possible. That is why we have created a guide to help ease the process. If you have a scheduled exam, we will make every attempt to reach you prior to your service so that we can register you in advance and expedite your visit.
During registration, you will be required to sign the following:
- Consent for treatment
- Authorization to bill insurance
If you are an Obstetrics patient please print, complete and bring in the following form or fax to 408-559-2675:
If you are a Medicare recipient, you will be required to sign:
- Medicare Patient Rights Statement
If you are a Medicare recipient, you will be asked to complete:
- Medicare Secondary Payor Questionnaire
If you are a Medicare recipient, you may be asked to sign:
- Advance Beneficiary Notice
If you are a Champus recipient, you will be required to sign:
- Champus Rights Statement
Remember to bring the following items to your appointment:
- Social Security Card
- All active insurance cards
- Picture ID
- Living Will or Durable Power of Attorney for Healthcare Document, if you have one
- Your physician's treatment orders