McLaren Central Michigan Online Pre Registration Form
If you are scheduled for a procedure or test, you may pre-register by using our online registration form.  This form must be completed and submitted at least 24 hours prior to your scheduled appointment.

Co-Insurance and Deductibles

Co-insurance and deductible payments are due at the time of service. McLaren-Central Michigan accepts cash, checks, VISA, MasterCard, American Express, and debit cards. If you are unable to pay your co-insurance or deductible at the time of service, we request a deposit be made toward the out-of-pocket expense.

Estimates and Payment Arrangements

The cost of health care is a concern to everyone, whether covered by medical insurance or paying for health care services out-of-pocket.  If you are scheduled for a test or procedure and would like McLaren-Central Michigan to estimate the cost, a representative can assist you.

Remember that a health care estimate will probably not match total charges once services are provided. McLaren-Central Michigan can provide you with a specific cost for each item or service: chest x-ray, specific laboratory test, CT scan, medical supplies, room charge, or other specific services. It is difficult to determine the exact price for a surgical procedure or admission as each patient is unique. Goods and services are provided as necessary based on each individual’s medical condition.

If you would like an estimate please call (989) 772-6778.

McLaren-Central Michigan can set up payment arrangements to assist patients in meeting out-of-pocket health care expenses. Please contact the McLaren-Central Michigan Financial Counselor at (989) 772-6792 for information on rules and requirements for payment arrangements.
*Indicates required information

Appointment Information:
Type of Service*
If Other, please specify:
Date of Service
Use Due Date if Maternity
Section 2:
Ordering Physician*
Family Physician*
Diagnosis/Symptoms or Reason for test*
Section 3: Patient Demographic Information:
Patient Legal Name (last name, first name, middle initial, Jr., Sr., etc.*
Previous name/maiden name
Date of Birth*
Mailing Address*
If you are a college student, please type your local address
Telephone Number*
Alternate number or cell phone number
Social Security Number (optional)
If Other, please specify:
Religion (optional)
Marital Status*
Spouse's full name
Email Address for pre registration confirmation*
Are you employed outside the home?*
Employer Name if applicable
Employer Address
Employer Phone
Are you retired?*
If retired, your approximate retirement date?
What company did you retire from?
Emergency Contact Information:
Emergency contact name*
Address* Telephone Number*
Alternative Telephone Number
Responsible Party:
Patient is a minor*

If patient is a minor, please skip next 3 questions and fill in information for responsible party (Parent/Guardian patient lives with):
I, the patient, am 18 years of age or older

I, the patient, am a college student
If yes, please type permanent address here and skip to Section 4
Responsible Party legal name.
Previous name/maiden name
Responsible Party date of birth
Responsible Party Permanent address
Responsible Party Telephone number
Alternate phone number
Responsible Party social security number
Responsible Party gender
Responsible Party marital status
Responsible Party employer
Employer's Address
Section 4: Insurance Information:
Name of Primary Insurance*
Contract or policy number*
Group Number*
Policy holder name as it appears on your insurance card*
Policy holder date of birth*
Policy Holder Employer*
Insurance address (not required for Medicare or Medicaid)
Insurance Telephone Number*
Secondary Insurance Name
Contract or policy number
Group number
Policy holder name as it appears on your insurance card
Policy holder date of birth
Policy holder employer
Insurance address (no address required for Medicare or Medicaid)
Insurance Telephone Number
Third Insurance Name
Contract or policy number
Group number
Policy holder name as it appears on your insurance card
Policy holder date of birth
Policy holder employer
Insurance address (no address required for Medicare or Medicaid)
Insurance Telephone Number
Are the services related to an accident or injury?*
If accident or injury, what was the date of the accident/injury?
Are the services payable by Workers Compensation?*
If workers compensation, please provide workers comp insurance information.
Name of Insurance, Claim Number, Adjustor Name and Telephone Number, and Claims Mailing Address (If available)

Are the services payable under a liability claim?*
Liability Claim Information
Is the accident or injury
Section 5: We are required to ask:
Information Directory:
If someone calls to verify you are at McLaren-Central Michigan we will confirm your admission/registration (outpatient) and condition (stable, critical, etc).
You have the right to restrict your information in the directory. If you elect to restrict your information in the directory, you are responsible to inform family and friends regarding your location in the hospital.
By answering "no" below, if someone calls or inquires about you we will state, "We have no information about that person."
Do you want to be included in the Information Directory?*
Durable Power of Attorney:
Do you have a Durable Power of Attorney or Advanced Directive for Health Care?*

If no, would you like to receive information on Durable Power of Attorney and Advance Directives?*

Do you wish to receive confirmation that your pre registration was processed?*

Do we have your permission to call you at home if we have a question about your pre registration?*

Is there anything else you'd like us to know?
Canceling or Rescheduling an Appointment:
If you need to cancel or re-schedule a surgical procedure, endoscopy, or Heart & Vascular procedure, please contact your physician’s office.
If you need to cancel or re-schedule an X-ray, CT, Ultrasound, Mammogram, MRI exam, or other diagnostic imaging procedure, please contact the Central Scheduling Office at (989) 772-6878.