Mammography Pre-Registration

Welcome to Middlesex Hospital's On-line Pre-Registration for Screening Mammogram Appointments

As a convenience for our patients, Middlesex Hospital offers pre-registration for patients with a mammogram appointment.

Pre-registering for an upcoming screening mammogram appointment allows you to go directly to the appointment location. Your registration paperwork will be completed and waiting for you.

In order to pre-register successfully, you must have a scheduled mammogram appointment. If you do not have an appointment and have a physician order for a mammogram, please call 860-358-2600, Monday - Friday, 8 a.m. - 6:00 p.m.

Appointment

(mm/dd/yyyy) Appointment date must be at least 24 hours in the future.

Patient Information

(i.e. maiden name)

(mm/dd/yyyy)

You must provide at least one phone number.

If provided, we will email you a confirmation that your pre-registration was received.

(mm/dd/yyyy)

Guarantor Information (for patients under age 18)

(i.e. maiden name)

(mm/dd/yyyy)

Next of Kin (Person you would like called in case of emergency)

(mm/dd/yyyy)

(mm/dd/yyyy)

Insurance or Medicaid Information
Special Program

EDP (Early Detection Program)

Insurance Company 1
Insurance Company 2 (if applicable)
MSP Questionnaire (to be completed by all patients on Medicare)

1. Is this visit covered under Black Lung benefits, Dept. of Veteran Affairs, or other grants?

2. Was your illness/injury due to an Automobile or other accident?

3. Was your illness/injury due to an accident or illness that occurred at work?

4. Do you or your spouse work for a company that provides you with health insurance?

5. Are you entitled to Medicare based on

Do you want to receive appointment reminders?

Text *

Voice Mail *

Email *

Verification

We want to make sure you are human :)

Leave this field empty

Reminder

Please bring all insurance cards and a photo ID at time of service. Co-pays, deductibles or other patient responsibility will be collected at time of service. Financial Assistance or Payment arrangements are available for those who qualify. For more information, call 860-358-4870 or refer to www.midhosp.org. Use keyword search "Financial Assistance" or "Billing".

28 Crescent Street
Middletown, CT 06457


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860-358-6000
info@midhosp.org