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Maternity Pre-admission

Notice of Privacy Practices
I accept the terms and conditions
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Mother's Information

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Marital Status
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Employment - Section II



Insurance - Section III (Insured Patients Only)

Note: If you are not insured, and paying "out of pocket" (by cash, check, or credit card), click "No" below and proceed to section IV.

Do you have insurance?
If you clicked "yes", complete the following fields:
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Insurance Policy Owner Is The:



Insurance company #1

Is Pre-certification Required



Insurance company #2

Insurance company #2
Is Pre-certification Required?



Physician Information - Section IV

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2701 North Decatur Road Decatur, GA 30033
404.501.1000
Patient Inquiries: 404.501.5200

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