Fairview Pre-Registration Form

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charset=UTF-8"/> <title>Fairview Pre-Registration Form</title>  <link href="/web/20110809231815cs_/https://sslforms.fairview.org/fv/groups/ssadminview/documents/web_assets/fv_style.css" rel="stylesheet" type="text/css"/> <link href="/web/20110809231815cs_/https://sslforms.fairview.org/fv/groups/ssadminview/documents/web_assets/fv_submenus.css" rel="stylesheet" type="text/css"/> <link href="/web/20110809231815cs_/https://sslforms.fairview.org/fv/groups/ssadminview/documents/web_assets/fv_structure.css" rel="stylesheet" type="text/css"/> <link href="/web/20110809231815cs_/https://sslforms.fairview.org/fv/groups/ssadminview/documents/web_assets/fv_left-nav.css" rel="stylesheet" type="text/css"/> <link href="/web/20110809231815cs_/https://sslforms.fairview.org/fv/groups/ssadminview/documents/web_assets/fv_printingcss.css" rel="stylesheet" type="text/css" media="print"/>  <link href="/web/20110809231815cs_/https://sslforms.fairview.org/2/css/fv_pharm.css" rel="stylesheet" type="text/css"/> <link href="/web/20110809231815cs_/https://sslforms.fairview.org/2/css/fv_subtabs-steps.css" rel="stylesheet" type="text/css"/> <link href="/web/20110809231815cs_/https://sslforms.fairview.org/2/css/fv_original_c_093839.css" type="text/css" rel="StyleSheet"/>      <link rel="stylesheet" type="text/css" href="/web/20110809231815cs_/https://sslforms.fairview.org/preregistration/prereg.css"/> <style type="text/css"> font.Incomplete { color: Red; 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font-weight: bold; font-size: 16px; vertical-align: middle; color: #ffffff; padding-top: 3px; border-bottom: 1px groove; font-family: MS Sans Serif; height: 30px; background-color: #3C86E6;">     Pre-Registration Form</div> </div> </td> </tr> </table> <form name="firstPage" id="firstPage" action="prereg.asp" method="post"> <table width="730" bgcolor="#ffffff" class="center"> <tr> <td> <center style="width: 730px"> <b><font size="large">FAIRVIEW HEALTH SERVICES WEB PRE-REGISTRATION FORM</font></b></center> <br/> <br> </td> </tr> <tr> <td class="style3"> <p> Welcome to Fairview Health Services Secured On-Line Preregistration form.  Please do not complete this form if your visit is just for a physician clinic visit.  You may also call 612-672-2000 for any questions pertaining to this form.  In order to complete the online form, please have the following information available:</p> <ul> <li>Your date of service</li> <li>The name of the site that you are having services.</li> <li>The name of your physician performing the procedure, the name of your primary care physician and the name of your referring physician.</li> <li>Demographic information such as address and phone numbers (home, work and cell phone).</li> <li>Next of kin information (name and phone number)</li> <li>Employer information (name, address, and phone number)</li> <li>Insurance information and/or billing information. (please have all insurance cards and/or billing information readily accesible).<br/> </li> <li><b>If you need help, click on the  </b><span id="span1" style="border-right: 1px groove; border-top: 1px groove; font-weight: bold; font-size: 11px; vertical-align: middle; border-left: 1px groove; width: 20px; color: #ffffff; padding-top: 1px; border-bottom: 1px groove; font-family: MS Sans Serif; height: 22px; text-align: center; background-color: #3C86E6"><b><font color="yellow" face="arial" size="3">?</font></b></span>  <b>at the top of each section for definitions you may find helpful while filling out your form. For assistance, please call . <br/></li> </ul> </td> </tr> <tr> <td align="center"> <table width="730" class="center"> <tr> <td align="center"> <input type="button" class="btn4" value=" " id="01" onmouseover="swapStep('01','over');" onmouseout="swapStep('01','out');"/> </td> <td align="center"> <input type="submit" class="btn5" value=" " onclick="var save =checkSaveChanges(); if(save){ firstPage.hidden1.value='firstPage';}else{ firstPage.hidden1.value='back';firstPage.hidden2.value='PageTwo'};" id="02" onmouseover="swapStep('02','over');" onmouseout="swapStep('02','out');"/> </td> <td align="center"> <input type="submit" class="btn6" value=" " onclick="var save =checkSaveChanges(); if(save){ firstPage.hidden1.value='firstPage'; firstPage.hidden2.value='PageThree'}else{firstPage.hidden1.value='next'; firstPage.hidden2.value='PageThree'};" id="03" onmouseover="swapStep('03','over');" onmouseout="swapStep('03','out');"/> </td> <td align="center"> <input type="submit" class="btn7" value=" " onclick="var save=checkSaveChanges(); if(save){firstPage.hidden1.value='firstPage'; firstPage.hidden2.value='verifyPage'}else{firstPage.hidden1.value='verifyPage'}" id="04" onmouseover="swapStep('04','over');" onmouseout="swapStep('04','out');"/> </td> </tr> <tr> <td align="center"> <font class="Incomplete"> (Incomplete) </font> </td> <td align="center"> <font class="Incomplete"> (Incomplete) </font> </td> <td align="center"> <font class="Incomplete"> (Incomplete) </font> </td> <td>  </td> </tr> </table> </td> </tr> <tr> <td>  </td> </tr> <tr> <td align="center"> <b>Please note:</b> </td> </tr> <tr> <td align="center"> <b>To protect the data you are entering, your internet session will automatically timeout after one hour of no activity. Please take the time to gather all required information beforehand to avoid re-entry. <p> Thank You.</p></b> </td> </tr> <tr> <td align="center"> <div class="WarningMessage"> </div> </td> </tr> <tr> <td> <table width="730" bgcolor="white"> <tr> </tr> <tr> <a name="VisitProcedureInfo"></a> <td width="30"> </td> <td width="700"> <div id="Div4" style="border-style: groove; border-color: inherit; border-width: 1px; font-weight: bold; font-size: 11px; vertical-align: middle; color: #ffffff; padding-top: 1px; font-family: MS Sans Serif; height: 22px; background-color: #3C86E6; width: 698px;">   Visit Information</div> </td> </tr> </table> </td> </tr> <tr> <td align="center"> <table width="650" class="center"> <tr> <td> <div class="WarningMessage"> </div> </td> </tr> <tr> <td align="center"> <table width="650" style="background-color: #FFFFFF" class="center"> <tr> <td align="right" width="350"> <font color="red">*</font>Facility   </td> <td width="1">  </td> <td width="249"> <select id="DemFacilityCode" name="DemFacilityCode" style="left: 50px; width: 340px; top: 1px" class="" onchange="refreshDocument(); setItemChange()" tabindex="100"> <option value="" selected> Select Facility</option> <option value="flk">Fairview Lakes Medical Center</option> <option value="mgv">Fairview Maple Grove Medical Center</option> <option value="fnh">Fairview Northland Medical Center</option> <option value="frh">Fairview Ridges Hospital</option> <option value="fsh">Fairview Southdale Hospital</option> <option value="mgb">Maple Grove Hospital Birth Center</option> <option value="umc">University of Minnesota Amplatz Children's Hospital</option> <option value="umn">University of Minnesota Medical Center, Fairview</option> </select> </td> </tr> <tr> <td align="right" width="350"> <font color="red">*</font>Date of visit   </td> <td width="1">  </td> <td width="249"> <input type="button" id="btnDatePicker" name="btnDatePicker" onclick="pickDate(DemDateOfAdmOrVisit); setItemChange()" size="4" value="Choose Date" tabindex="120"/>   <input style="font-size: small" id="DemDateofAdmOrVisit" name="DemDateOfAdmOrVisit" class="" value="" readonly id="Text1" size="15" tabindex="110"/> </td> </tr> <tr> <td align="right" width="350"> <font color="red">*</font>Reason for visit </td> <td width="1">  </td> <td width="249"> <select id="DemReasonForAdmitCode" name="DemReasonForAdmitCode" style="left: 50px; width: 230px; top: 1px" onchange="setReasonForVisitOther();setItemChange()" tabindex="141"> <option value=""> Select Reason For Visit</option> <option value="1">Outpatient Surgery or Endoscopy</option> <option value="2">Maternity</option> <option value="3">Lab</option> <option value="4">Radiology, MRI or CT</option> <option value="5">Inpatient Surgical/Non-Surgical</option> <option value="Other">Other</option> </select> </td> </tr> <tr> <td align="right" width="350"> <div id="DivReasonForVisit" style="display: none"> If other, please enter reason for visit    </div> </td> <td width="1"> <div id="DivReasonForVisitSpace" style="display: none">   </div> </td> <td width="249"> <div id="DivReasonForVisitValue" style="display: none"> <input type="text" name="DemReasonForAdmitOther" id="DemReasonForAdmitOther" class="" value="" maxlength="100" size="60" tabindex="149" onchange="setItemChange()"/> </div> </td> </tr> <tr> <td align="right" width="350"> <font color="red">*</font>Is this visit due to an accident or work related injury? </td> <td width="1">  </td> <td width="249"> Yes<input type="radio" class="" id="AccVisitDueToAccidentYes" name="AccVisitDueToAccident" value="Yes" onclick="showHideDiv('show','DivAccidentInfo');showHideDiv('show','DivAccidentTime');showHideDiv('show','DivAccidentType');showHideDiv('show','DivAccidentOtherDisplay');showHideDiv('show','DivAccidentCause');showHideDiv('show','DivAccidentLocation');" tabindex="160" onchange="setItemChange()"/>    No <input type="radio" class="" id="AccVisitDueToAccidentNo" name="AccVisitDueToAccident" value="No" onclick="showHideDiv('hide','DivAccidentInfo');showHideDiv('hide','DivAccidentTime');showHideDiv('hide','DivAccidentType');showHideDiv('hide','DivAccidentOtherDisplay');showHideDiv('hide','DivAccidentCause');showHideDiv('hide','DivAccidentLocation');" tabindex="161" onchange="setItemChange()"/> </td> </tr> <tr id="DivAccidentInfo" style="display: none" class="center"> <td align="right" width="350"> Date of Injury:  </td> <td width="1">  </td> <td width="249"> <input type="text" id="AccInjuryDate" name="AccInjuryDate" value="" maxlength="50" size="50" tabindex="162" onchange="setItemChange()"/>     </td> </tr> <tr id="DivAccidentTime" style="display: none" class="center"> <td align="right"> Time of Injury:  </td> <td>  </td> <td> <input type="text" id="AccInjuryTime" name="AccInjuryTime" value="" maxlength="30" size="30" tabindex="163" onchange="setItemChange()"/> </td> </tr> <tr id="DivAccidentType" style="display: none" class="center"> <td align="right"> Accident Type:  </td> <td>  </td> <td> Auto-related  <input type="radio" id="AccTypeAuto" name="AccType" value="Auto" onclick="showHideDiv('hide','DivAccidentOtherDisplay'); setItemChange()" tabindex="1330"/>       Work-related  <input type="radio" id="AccTypeWork" name="AccType" value="Work" onclick="showHideDiv('hide','DivAccidentOtherDisplay'); setItemChange()" tabindex="164"/>           Other   <input type="radio" id="AccTypeOther" name="AccType" value="Other" onclick="showHideDiv('show','DivAccidentOtherDisplay'); showHideDiv('show','DivAccidentOther');showHideDiv('show','DivAccidentOtherExplain'); setItemChange() " tabindex="165"/> </td> </tr> <tr id="DivAccidentOtherDisplay" style="display: none" class="center"> <td align="right"> <div id="DivAccidentOther" style="display: none"> <font color="red">*</font>If other, please explain: </div> </td> <td>  </td> <td> <table> <tr id="DivAccidentOtherExplain" style="display: none"> <td> <textarea id="AccTypeOtherExplain" name="AccTypeOtherExplain" class="" cols="30" rows="4" onkeydown="limitTextArea(this,250);" tabindex="166" onchange="setItemChange()"></textarea> </td> </tr> </table> </td> </tr> <tr id="DivAccidentCause" style="display: none" class="center"> <td align="right"> Cause of Injury? </td> <td>  </td> <td> <input type="text" id="AccCause" name="AccCause" value="" maxlength="50" size="50" tabindex="167" onchange="setItemChange()"/> </td> </tr> <tr id="DivAccidentLocation" style="display: none" class="center"> <td align="right"> Where accident / injury occured </td> <td>  </td> <td> <input type="text" id="AccWhere" name="AccWhere" value="" maxlength="50" size="50" tabindex="168" onchange="setItemChange()"/> </td> </tr> <tr> <td align="right" width="350"> <font color="red">*</font>Would you like to be listed in the patient directory on the date of your procedure? </td> <td width="1">  </td> <td class="style1"> Yes <input type="radio" class="" id="DemPatientDirectoryYes" name="DemPatientDirectory" value="Yes" tabindex="169" onchange="setItemChange()"/>   No <input type="radio" class="" id="DemPatientDirectoryNo" name="DemPatientDirectory" value="No" tabindex="170" onchange="setItemChange()"/> </td> </tr> <tr> <td>  </td> <td>  </td> <td class="style1"> (If <b>Yes</b>, your name, location in the hospital, phone number, if you are an inpatient and general condition will be provided if callers ask to speak to you. If <b>No</b>, they will be told you are not a patient at this facility.) </td> </tr> </table> </td> </tr> <tr> <td> <table width="730" bgcolor="white"> <tr> </tr> <tr> <td width="30"> <a name="PhysicianInfo"></a> <div id="rulePatientHelp" style="border-right: 1px groove; border-top: 1px groove; font-weight: bold; font-size: 11px; vertical-align: middle; border-left: 1px groove; width: 20px; color: #ffffff; padding-top: 1px; border-bottom: 1px groove; font-family: MS Sans Serif; height: 22px; text-align: center; background-color: #3C86E6"> <b><a onclick="mypopup('/inc/downloads/c_178638.html')" href="javascript: void(0)"><font color="yellow" face="arial" size="3">?</td> <td width="700"> <div id="rulePatientInformation" style="border-right: 1px groove; border-top: 1px groove; padding-left: 5px; font-weight: bold; font-size: 11px; vertical-align: middle; border-left: 1px groove; width: 700px; color: #ffffff; padding-top: 1px; border-bottom: 1px groove; font-family: MS Sans Serif; height: 22px; background-color: #3C86E6" "> Physician Information</div> </td> </tr> </table> </td> </tr> <tr> <td align="center"> <table width="730" class="center"> <tr> <td> <div class="WarningMessage"> </div> </td> </tr> <tr> <td width="240"> <table style="width: 240px"> <tr> <td width="100"> </td> <td width="1"> </td> <td> <font color="blue"><b>Admitting Physician</b></font> </td> </tr> <tr> <td align="right" width="100"> <font color="red"> *</font>Last Name </td> <td width="1"> </td> <td> <input type="text" class="" id="PhyAdmittingLName" name="PhyAdmittingLName" value="" maxlength="25" size="20" tabindex="1000" onchange="setItemChange()"/> </td> </tr> <tr> <td align="right"> <font color="red">*</font>First Name </td> <td> </td> <td> <input type="text" class="" id="PhyAdmittingFName" name="PhyAdmittingFName" value="" maxlength="20" size="20" tabindex="1010" onchange="setItemChange()"/> </td> </tr> <tr> <td>  </td> <td>  </td> <td>  </td> </tr> </table> </td> <td width="240"> <table style="width: 240px"> <tr> <td width="100"> </td> <td width="1"> </td> <td align="left"> <font color="blue"><b>Primary Care</b></font> </td> </tr> <tr> <td align="right"> <font color="red">*</font>Last Name </td> <td width="1"> </td> <td> <input type="text" class="" id="PhyPrimaryLName" name="PhyPrimaryLName" value="" maxlength="25" size="20" tabindex="1100" onchange="setItemChange()"/> </td> </tr> <tr> <td align="right"> <font color="red">*</font>First Name </td> <td> </td> <td> <input type="text" class="" id="PhyPrimaryFName" name="PhyPrimaryFName" value="" maxlength="20" size="20" tabindex="1100" onchange="setItemChange()"/> </td> </tr> <tr> <td align="right"> <font color="red">*</font>Primary  Clinic </td> <td> </td> <td> <input type="text" class="" id="PhyHomeClinic" name="PhyHomeClinic" value="" maxlength="50" size="20" tabindex="1110" onchange="setItemChange()"/> </td> </tr> </table> </td> <td width="240"> <table style="width: 240px"> <tr> <td width="100"> </td> <td width="1"> </td> <td align="left"> <font color="blue"><b>Referring Physician</b></font> </td> </tr> <tr> <td align="right">  Last Name </td> <td width="1"> </td> <td> <input type="text" id="PhyReferringLName" name="PhyReferringLName" value="" maxlength="25" size="20" tabindex="1200" onchange="setItemChange()"/> </td> </tr> <tr> <td align="right">  First Name </td> <td> </td> <td> <input type="text" id="PhyReferringFName" name="PhyReferringFName" value="" maxlength="20" size="20" tabindex="1210" onchange="setItemChange()"/> </td> </tr> <tr> <td align="right">  Clinic Name </td> <td> </td> <td> <input type="text" id="PhyReferringClinic" name="PhyReferringClinic" value="" maxlength="50" size="20" tabindex="1211" onchange="setItemChange()"/> </td> </tr> </table> </td> </tr> </table> <table width="699" class="center"> <tr> <td width="233"> </td> <td width="233"> </td> <td width="233"> </td> </tr> <tr> <td> </td> <td> </td> <td> </td> </tr> <tr> <td> </td> <td> </td> <td> </td> </tr> <tr> <td align="center"> <input type="button" class="btn1" id="Clear" onclick="confirmClear()"/> </td> <td align="center"> </td> <td align="left"> <input type="submit" class="btn2" id="nextButton" tabindex="1212" value=" " onclick="firstPage.hidden1.value='firstPage';"/> </td> <input type="hidden" name="hidden1" value=""/> <input type="hidden" name="hidden2" value=""/> </tr> <tr> <td> </td> <td> </td> <td> </td> </tr> <tr> <td> </td> <td> </td> <td> </td> </tr> <tr> <td> </td> <td> </td> <td> </td> </tr> </table> </td> </tr> </table> </td> </tr> </table> </form>  </div>   <div class="clear"></div> </div> </div>    <div id="footerContainer" class="footerSwoosh_above png"> <div class="footerNavBox"> <div id="footerNav"> <div id="Footer_Element_1"></div> <div class="clear"> </div> </div> <div id="footerSubNav"> <div id="Footer_Element_2"></div> <div class="clear"> </div> </div> <div id="Footer_Element_3"></div> <div class="clear"> </div> </div> <div class="footerInfo"> <div id="Footer_Element_4"></div> </div> <div class="clear"> </div> <div class="clear"> </div> </div> <script type="text/javascript"> var currentServerContext = escape(document.location); 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