Within Banner If intending to schedule an appointment with Custer Health, complete and submit the following information. Complete and submit the pre-registration for EACH person that will be schedule for an appointment. Allow 24 hours for the system to update before calling your local office to schedule an appointment. *WIC appointment - Please call your local WIC office to schedule an appointment. **CPR and 1st Aid classes - Please click here to register. Demographic Information Full Legal Name First Middle Last Date of Birth Gender - Select -ManWomanNon-binaryAgender/GenderlessAndrogyne/AndrogynousAporagenderBigenderDemi-agenderDemi-boyDemi-fluidDemi-girlDemi-genderDemi-non-binaryGenderqueerGenderfluxGenderfluidGender-indifferentGender-neutralGraygenderIntergenderMaveriqueMaxigenderMultigender/PolygenderNeutroisPangender/OmnigenderTrigenderTwo-spiritPrefer Not to Answer Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code County Birth State or Country (if not born in the USA) Cell Number Home Phone Number Email Mother's Name (First - Last) If client is 18 years or younger Preferred Language Preferred Language - Select -EnglishSpanishOther… Enter other… Race Caucasian Latino/Hispanic Middle Eastern African Caribbean South Asian East Asian Mixed Other… Enter other… Is client Hispanic or Latino? Yes No Is client a Refugee? Yes No Insurance Information Does client have health insurance? Yes No If client has one of the following Insurance providers as their Primary Insurance, complete the Primary and Secondary Insurance Sections: Sanford, BCBS, Medicaid, Mediare, Humana, Tricare, Champ VA, Railroad Medicare, or Medica (Zoster or Td/Tdap are not covered) Primary Insurance Insurance Company Name Sanford BCBS Medicaid Medicare Humana Tricare Champ VA Medica None Policy Number Group # (if applicable) Card Holder's Information Legal Name First Middle Last Date of Birth Gender - None -ManWomanNon-binaryAgender/GenderlessAndrogyne/AndrogynousAporagenderBigenderDemi-agenderDemi-boyDemi-fluidDemi-girlDemi-genderDemi-non-binaryGenderqueerGenderfluxGenderfluidGender-indifferentGender-neutralGraygenderIntergenderMaveriqueMaxigenderMultigender/PolygenderNeutroisPangender/OmnigenderTrigenderTwo-spiritPrefer Not to Answer Relationship to Client Self Spouse Child Address (if different from the Client's address): Secondary Insurance Insurance Company Name Sanford BCBS Medicaid Medicare Humana Tricare Champ VA Medica None Policy Number Group # (if applicable) Card Holder's Information Legal Name First Middle Last Date of Birth Gender - None -ManWomanNon-binaryAgender/GenderlessAndrogyne/AndrogynousAporagenderBigenderDemi-agenderDemi-boyDemi-fluidDemi-girlDemi-genderDemi-non-binaryGenderqueerGenderfluxGenderfluidGender-indifferentGender-neutralGraygenderIntergenderMaveriqueMaxigenderMultigender/PolygenderNeutroisPangender/OmnigenderTrigenderTwo-spiritPrefer Not to Answer Relationship to Client Self Spouse Child Address (if different from the Client's address): Person Financially Responsible for Client First & Last Name Address (if different from the Client's address): Phone Number Relationship to Client Self Spouse Child Submit
