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 a.m. and 6:30 p.m.; after hours you can call the Admissions Department at (716) 568-3730.

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Fields marked with * are required.

Patient Information:
If Married, Spouse Information:
Patient Employer Information:
(Full-time, part-time, unemployed, etc.)
Emergency Information:
Medical Information:
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. Note: If your insurance company requires you to pay a co-payment for your Maternity Admit, please be prepared to make this payment prior to your discharge.

Are you covered by medical insurance?

If Yes, Please complete the following information for your Primary Insurance:

Person carrying the insurance policy:

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

Person carrying the insurance policy:

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Millard Fillmore Suburban Hospital • 1540 Maple Rd • Williamsville, NY 14221