Complete and submit the Online Pre-Registration
Form
As a commitment to providing excellent service for our customers, the Patient Access Department is providing patients the opportunity to pre-register for tests or procedures at any of our facilities. By taking a few minutes to complete the information in our online registration form, Patient Access is committed to using this information to reduce your registration time 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 email us at preaccesscenter@navicenthealth.org. We look forward to having the opportunity to serve you.
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 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 Navicent Health at (478) 633-1000 Home | Contact Us
