Complete connected care℠ A Circle Health Member

For Patients

Express Registration

For services and procedures such as CT scans and Ultrasounds an appointment needs to be booked through our Central Scheduling Department at 978-937-6023 PRIOR to completing the express registration form below. If you are not sure if you need an appointment, please contact the Central Scheduling Department.

For Walk-in services such as blood draws and X-rays please complete the express registration form below.

The online form must be completed at least 24 hours before your scheduled test or procedure or 24 hours in advance of when you plan to arrive for non-scheduled tests. To register for a Monday visit, you must complete the form by 5pm on the Friday prior.

 

As a convenience for patients, Lowell General Hospital offers pre-registration for procedures and tests you will have at the hospital. By pre-registering before your test, you may go directly to the department in which your test is scheduled.

You may register online here or by phone by calling 978-937-6429. Representatives are available Monday–Friday from 7:00am–6:00pm to assist you. You must have the following information available to do this:

  • Your insurance card
  • Name of the test you are registering for and your diagnosis
  • Referral form, doctor's orders, or letter, if appropriate
  • Information about your doctors, including names, addresses and phone numbers
  • Emergency contact information

IMPORTANT: Please complete ALL of the information on the registration form (required and not required) to insure that we can process your pre-registration in a timely and accurate manner. Incomplete form information may cause a delay in your registration process.

PLEASE NOTE: Fields marked with an asterisk (*) are required. If a field does not apply to you type "NA" or "Not Applicable."

Ooops! Please address the following:

Reason for Visit

Enter as MM/DD/YYYY

(i.e. CT scan, EKG, Lab work, blood draw, Mammography)

(i.e. Anemia, Back Pain, Shortness of Breath, Calcification)

Next »

PLEASE NOTE: Fields marked with an asterisk (*) are required. If a field does not apply to you type "NA" or "Not Applicable."

Ooops! Please address the following:

Patient Information

mm/dd/yyyy

Sex*

Race*

You may choose up to two

Ethnicity*

You may choose up to two

Do you consider yourself Hispanic, Latino or Spanish?

Previous Next

PLEASE NOTE: Fields marked with an asterisk (*) are required. If a field does not apply to you type "NA" or "Not Applicable."

Ooops! Please address the following:

Next of Kin

i.e. spouse, son, daughter, etc.

mm/dd/yyyy

Kin Address "Same As" Patient?*

Previous Next

PLEASE NOTE: Fields marked with an asterisk (*) are required. If a field does not apply to you type "NA" or "Not Applicable."

Ooops! Please address the following:

Insurance Information

Insurance Type*

Insurance Company

Policy Holder

Policy Holder "Same As" Patient?*

mm/dd/yyyy

Policy Holder Employer

Secondary Insurance Information -

Insurance Company

Policy Holder

Policy Holder "Same As" Patient?*

mm/dd/yyyy

Policy Holder Employer

Additional Insurance Information -

Insurance Company

Policy Holder

Policy Holder "Same As" Patient?*

mm/dd/yyyy

Policy Holder Employer

Do you have another insurance to add?

Previous Submit

Basic Medicare Information

Are you receiving Black Lung Benefits?*

Choose year first, then month.

Are the services to be paid by a government research program?*

Has the Department of Veteran Affairs authorized and agreed to pay for your care at this facility?*

Was the illness/injury due to a work-related accident/condition?*

Choose year first, then month.

Was the illness/injury due to a non-work related accident?*

Choose year first, then month.

Is no-fault insurance available?*

Is liability insurance available?*

Medicare Entitlement Information

PLEASE NOTE: Both "Age" and "ESRD" OR "Disability" and "ESRD" may be selected simultaneously, however an individual cannot be entitled to Medicare based on "Age" and "Disability" simultaneously.

Are you entitled to Medicare based on …*

Entitled to Medicare based on Age

Are you currently employed?*

Choose year first, then month.

Do you have a spouse who is currently employed?*

Choose year first, then month.

Do you have group health plan (GHP) coverage based on your own or a spouse's current employment?*

If you have GHP coverage based on our own current employment, does your employer that sponsors or contributes to the GHP employ 20 or more employees?*

If you have GHP coverage based on your spouse's current employment, does your spouse's employer that sponsors or contributes to the GHP employ 20 or more employees?*

Entitled to Medicare based on Disability

Are you currently employed?*

Choose year first, then month.

Do you have a spouse who is currently employed?*

Choose year first, then month.

Do you have group health plan (GHP) coverage based on your own or a spouse's current employment?*

If you have GHP coverage based on our own current employment, does your employer that sponsors or contributes to the GHP employ 100 or more employees?*

If you have GHP coverage based on your spouse's current employment, does your spouse's employer that sponsors or contributes to the GHP employ 100 or more employees?*

Are you covered under the GHP of a family member other than your spouse?*

If you have GHP coverage based on a family member's current employment, does your family member's employer that sponsors or contributes to the GHP employ 100 or more employees?*

Entitled to Medicare based on ESRD

Do you have group health plan (GHP) coverage?*

If applicable, your GHP information
If applicable, your spouse's GHP information
If applicable, your family member's GHP information

Have you received a kidney transplant?*

Choose year first, then month.

Have you received maintenance dialysis treatments*

Choose year first, then month.

Choose year first, then month.

Was your initial entitlement to Medicare based on ESRD?*

Does the working aged or disability MSP provision apply?*

Other Insurance

Previous Submit

Service Locations

Click on a link below for address & hours

Lowell General Hospital
Main Campus
Saints Campus

Patient Service Centers
Billerica
Chelmsford
Dracut
Tewksbury Clark Road
Tewksbury Main Street
Westford

Center for Weight Management
Chelmsford
North Andover

Women's Imaging Center
Chelmsford

Urgent Care Centers
Billerica
Dracut
Tewksbury
Westford

 

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