The Medical Center of Central Georgia

Complete and submit the Online Pre-Registration Form

As a commitment to excellence in service for you, our customers, the Patient Access Department is providing our patients the opportunity to pre-register for their test or procedure for any of our facilities by taking a few minutes to complete the pre-registration process.  Patient Access is committed to reduce your time of registration on the day of your service.  If you have any questions related to the pre-registration process, please contact our Pre-Access Center at 478- 633-1352 or visit us at 3780 Eisenhower Pkwy Suite 3. You can also email us at The Pre-Access Center with any questions you may have.

Fields with an * are required

You will be offered the opportunity to preview your information prior to submission. Once submitted, you will also be offered an opportunity to print the information you have provided.

SECTION 1 - PATIENT INFORMATION
* LAST NAME
* FIRST NAME
* MIDDLE NAME
* STREET ADDRESS
RT# / LOT# / APT#
* CITY
* STATE
* ZIP CODE
* COUNTY OF RESIDENCE
HOME PHONE
- -
* SOCIAL SECURITY NUMBER
- -
* DATE OF BIRTH
   
CELL PHONE
- -
* RACE
* GENDER
* MARITAL STATUS
EMAIL
 RELIGION
* DO YOU HAVE A LIVING WILL? If yes, please bring a copy with you.
Yes    No If no, you can review a living will and print it if desired by clicking here
* DO YOU HAVE DURABLE POWER OF ATTORNEY?    If no, you can review a living will and print it if desired by clicking here
Yes    No

 
SECTION 2 - EMPLOYMENT INFORMATION
(Current or Most Recent Employer)
EMPLOYER NAME

WORK PHONE
- -

EMPLOYMENT STATUS
EMPLOYER ADDRESS
CITY
ST
ZIP CODE
OCCUPATION
EFFECTIVE EMPLOYMENT DATE
   
LAST DAY WORKED
   

 
SECTION 3 - SERVICE/PROCEDURE INFORMATION
* PROCEDURE / TEST / SERVICE  * DIAGNOSIS * LOCATION OF TEST
* PROCEDURE DATE (If less than four days from now contact our Pre-Access Center at 478-633-1352 to verify you registration.)
   
* PHYSICIAN NAME
* IS DIAGNOSIS/TEST RELATED TO AN ACCIDENT?    YesNo 

If yes:
(Please bring a copy of the accident report with you.)

Date and Time of Accident:
      Hr. Min.

Place


Nature

 
SECTION 4 - FINANCIAL RESPONSIBILITY INFORMATION

Is the Patient under 18 or over 18 and a full time college student?
Yes    No


RELATIONSHIP TO PATIENT 
LAST NAME
FIRST NAME
MIDDLE NAME
STREET ADDRESS
RT# / LOT# / APT#
CITY
STATE
ZIP CODE
COUNTY OF RESIDENCE
HOME PHONE
- -
SOCIAL SECURITY NUMBER
- -
DATE OF BIRTH
   
CELL PHONE
- -
RACE
GENDER
MARITAL STATUS
(Current or Most Resent Employer)
EMPLOYER NAME
WORK PHONE
- -
EMPLOYMENT STATUS
EMPLOYER ADDRESS
CITY
STATE
ZIP CODE
OCCUPATION
EFFECTIVE EMPLOYMENT DATE
   
LAST DAY WORKED
   

 
SECTION 5 - INSURANCE INFORMATION
RELATIONSHIP TO PATIENT  

WHAT TYPE OF INSURANCE DO YOU HAVE:   Commercial   Medicare   Medicaid    None

Primary Insurance Information as listed on your insurance card. If uninsured, please type "none" in the Insurance Company Name and contact the Pre-Access Center at (478) 633-1352 to make payment arrangements

INSURED NAME
INSURED DATE OF BIRTH
   
INSURED EMPLOYER NAME
SOCIAL SECURITY NUMBER
- -
YOUR TYPE PLAN  
INSURANCE COMPANY NAME
INSURANCE POLICY NUMBER
INSURANCE GROUP NUMBER
CUSTOMER SERVICE / BENEFITS PHONE
- -
CLAIM MAILING ADDRESS
CITY
STATE
ZIP CODE
PRECERTIFICATION NUMBER *Obtain this information from your physician.
COMMENTS 

 
MEDICARE (If applicable)
MEDICARE NUMBER 
PART A
Yes
   No
PART B
Yes
   No
Are you a hospice patient? Yes   No
PART A EFFECTIVE DATE
   
PART B EFFECTIVE DATE
   
If yes, are you being admitted as a result of your hospice diagnosis?  Yes   No
HAS PATIENT BE AN INPATIENT IN A HOSPITAL IN THE LAST 60 DAYS?   
Yes
   No

If yes, where?
PATIENT'S RETIREMENT DATE
   
SPOUSE'S RETIREMENT DATE
   


 
MEDICAID (If applicable)
MEDICAID RECIPIENT'S NAME (Exactly as it  appears on the card) 
MEDICAID ID NUMBER 
TYPE OF MEDICAID  If Ga Better Health - who is your primary care provider (this information is found on your insurance card).
  

 
SECONDARY INSURANCE INFORMATION
RELATIONSHIP TO PATIENT  
INSURED NAME
INSURED DATE OF BIRTH
   
INSURED EMPLOYER NAME
INSURED SOCIAL SECURITY NUMBER
- -
YOUR TYPE PLAN
 
INSURANCE COMPANY NAME
INSURANCE POLICY NUMBER
INSURANCE GROUP NUMBER
CUSTOMER SERVICE / BENEFITS PHONE
- -
CLAIM MAILING ADDRESS
CITY
STATE
ZIP CODE
PRECERTIFICATION NUMBER *Obtain this information from your physician.
COMMENTS 

 
SECTION 6 - EMERGENCY CONTACT INFORMATION
RELATIONSHIP TO PATIENT 
LAST NAME
FIRST NAME
MIDDLE NAME
STREET ADDRESS
RT# / LOT# / APT#
CITY
STATE
ZIP CODE

HOME PHONE
- -
WORK PHONE
- -
CELL PHONE
- -

 
SECTION 7 - OTHER  INFORMATION
If someone calls or visits and asks about you, can we acknowledge that you're here? 

Other Person(s)in the household authorized to discuss patient and/or insurance information:


1.  

2.

 
SECTION 8 - COMMENTS

COMMENTS:


  

For more information, call The Medical Center of Central Georgia at (478) 633-1000
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