Pre-Register

Reduce Your Wait Time by Registering Online

Reduce your hospital wait time by pre-registering online! Simply fill out a pre-registration form online before your non-emergency appointment at Valley Baptist Medical Center — Harlingen. You can fill out this digital form in the convenience of your home, at work or anywhere you have Internet access.

To get started, simply fill out the form below. When you include a valid email address, we’ll send you a confirmation email within 72 hours that we’ve received your paperwork. We’ll also let you know if we need more information, but you may need to complete additional paperwork in person.

Be sure to bring your photo ID, insurance card, doctor’s order (if any) and referral (if required by insurance) to your visit.

Please fill out the Pre-Registration form below and we’ll confirm with you when received if you have included a valid email address. At that time we’ll also let you know if we need any additional information.

Fields marked with an asterisk(*) are required.

 

State or Country, if not U.S.
mm/dd/yyyy

Employment Information

Admission Information

Are you a returning patient?

mm/dd/yyyy

Spouse/Guarantor Information (Responsible Party)

999-999-9999

Emergency Notification

Primary Insurance Information

Are you insured?

999-999-9999
999-999-9999
mm/dd/yyyy

Secondary Insurance Information

Do you have secondary insurance?

999-999-9999
999-999-9999
999-99-9999
mm/dd/yyyy
999-99-9999
Best Way to Contact You?

If there is a financial liability (i.e. Co-payment, deductible, etc.) what is your preferred method of payment?


Newsletter Registration

 

Best Time to Contact You?


Your Privacy Is Important to Us

The information you provide will be shared with hospital-trained admissions representatives who will contact you directly via email or phone, within 72 hours of receipt of your admissions form. Your information is kept confidential and will become part of your medical record. Our hospitals adhere to the Health Insurance Portability and Accountability Act (HIPAA) of 1996.