We provide standardized forms for your use to document relevant patient history and other required information. Before your appointment with us, quickly and conveniently access our patient forms listed under Forms and Policies. Please bring your completed forms with you to our office at the time of your visit.
Answers to your queries about insurance, billing, credit and other topics are also available on the attached tabs.
Forms and Policies
- Demographic information form
- Intake form
- Billing and insurance
- Office and financial policies
- Parental consent for treatment
- Photo ID
- Release of medical records
Billing and Insurance
As a courtesy, we will file your claim to your primary insurance company one time for you. We also submit claims to secondary insurances.
With a few exceptions, we are participating providers with the insurance companies listed below.
Please note that this list is subject to change mid-year and you need to verify with your insurance company to ensure that the contract is still valid:
- America's PPO
- Blue Cross Blue Shield
- Blue Plus
For insurance holders who require a referral, please contact your primary care clinic to have a referral sent to Women & Adolescents Gynecology Center.
This should be done prior to the first visit. If these procedures are not followed and you would still like to consult our doctors, please understand that you will have to pay the charges incurred if the referral is denied.
- Bring your insurance card to every visit
- Be prepared to pay your co-payment or balance due at each visit
- If you have no insurance, a deposit of $200.00 is due prior to your visit