If you have insurance, please fill out below fields and bring your insurance card to your visit. There are some insurance plans we do not accept, please confirm your plan with our office, before your appointment.
Pap smears will be sent to Aurora Laboratory, unless insurance is through Anthem - Aurora accepts all other insurance plans.
I am aware that I am responsible for knowing my preferred lab and radilogy facility. I will be responsible for any charges incurred that my insurance may not cover.
Please be advised, if you are over 40, a Fecal Occult Blood (FOB) test will be performed during your annual exam in order to test for blood in your stool. This test may or may not be covered by insurance and the total cost is $28.00.
If you want your medical information shared with another person (spouse, parent/guardian, or relative) they must be listed on this form in order for us to share any information. This applies to minors as well. We will not share any health information without consent.
I, First Name Last Name give Women's Wellness Center permission to share my protected health information with First Name Last Name- relationship to patient .If you do not wish to have any of your health information shared with anyone, please type declined here: This applies to minors as well.
Name of Primary Care Physician First Name Last Name
This authorization is in effect for one year from date signed.
If yes, please list
If yes, list new and/or discontinued medications:
If yes, please explain:
Due to an increase in missed appointments, we are reminding patients that we require 24 hours notice for canceling or rescheduling appointments. We will be charging a $50 no call/no show fee for patients who fail to give 24 hours notice. We strive to provide excellent care for our patients and often have patients that need to be seen for an urgent issue. When a patient fails to notify our office of their cancellation, their appointment time, that could have been used to help another patient, is lost.
We value our patients' time and therefore, request that patients check in on time. Out of respect for other scheduled patients, late patients may need to reschedule.
I have read the above policy and understand that if I fail to provide 24 hours notice for canceling or rescheduling an appointment, I will be charged a $50.00 fee. No call/No show fees will need to be paid prior to scheduling another appointment.