• New Patient Registration & Consent Form

  • Patient Information

    Please complete the following patient information.
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  • Primary Insurance Information

    Please provide the following information about your primary insurance provider.
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  • Secondary Insurance Information

    Please provide the following information about your secondary insurance provider.
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  • Consent Form

    I hereby give my consent to be treated and accept the following terms:
  • Individual Document Acknowledgement

  • Release of Information, Benefit Assignment, Payment Authorization, Full Disclosure Statement and Agreement to Pay For Services

    I hereby authorize London Women's Care (LWC) to release any information necessary to process my insurance/Medicare claim, acquired in the course of my examination or treatment; to allow a photocopy of my signature to be used to process my insurance/Medicare claim for the period of LIFETIME. I claim any insurance benefits due me for services rendered by LWC and authorize and direct my carrier to issue payment check(s) directly to LWC. Regardless of my insurance benefits, if any, I understand that I am fully financially responsible for any and all fees incurred, and I agree to pay such fees in full. The insurance information furnished here represents a full disclosure of the insurance/third party benefits to which I am entitled. I understand that failure to disclose pre-certification/second opinion requirements for any and all plans to which I subscribe, may cause me to incur full liability for professional charges, as a result of non-payment by any carrier.
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