Maternity Pre-Admission Registration Form

In an effort to help make your maternity experience as easy and efficient as possible, we have provided this pre-admission registration form which may be submitted electronically at the mid-point of your pregnancy (at about 20 weeks). Pre-registering will ensure a faster, more streamlined admission process for you and your baby.

To ensure proper billing for your upcoming visit, please fill in all information below. You can contact the Labor & Delivery Registrar at (716) 568-6733 from Monday-Friday between 7:00 am and 6:30 pm; after hours you can call the Admissions Dept. at (716) 568-3730.

Thank you for choosing Millard Fillmore Suburban Hospital!

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Patient Information:
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Medical Information:
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Insurance Information:

The hospital accepts and bills most insurance companies as a courtesy to patients. Your insurer is under contract with you and/or your employer. If your insurance carrier does not make payment, the bill may ultimately be your responsibility. Please be aware that most insurance companies require prior authorization before an elective or urgent admission.

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If you have a secondary insurance policy, please complete the following information:

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