Patient Demographic Form Page 2

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Diagnostic Testing
: We recommend that you call your insurance company to be informed of your
benefits for any diagnostic test that The Women’s Center may order for you. These tests include
mammograms, DEXA scans, labs, CT’s, etc… You should inquire if pre-certification is needed. If so, you will
need to contact our office one week prior to your scheduled procedure to avoid claim denial.
Financial Policy
: To ensure accurate claim filing, please give your most current insurance card to our
registrar to be copied. If we are unable to verify your insurance, you will be responsible for payment at the
time of service. The Women’s Center participates with Medicare and most managed care plans. We will bill
your insurance company in compliance with the guidelines of our contract.
All co-payments, deductibles, and co-insurance as applicable are due at the time of
service.
Payment in full is due at the time of treatment for all private pay patients, Medicare
patients for non-assigned services (urinalysis, office visit, injections, etc..) and/or fees not
covered by your insurance.
If coverage is contingent on a referral of pre-certification, it is your responsibility to inform
us.
If you are unable to keep your appointment, we require a 24 hour cancellation notice or
your account will be charged $50.
We accept cash, check, and the following credit cards: Visa, MasterCard, and Discover.
Return checks are not handled in the office, they are handled by Check Care.
Any outstanding account turned over to a collection agency will be charged an additional
$35.00 fee.
I hereby authorize The Women’s Center, PC to provide me with medical treatment. I understand
and agree that I am responsible for all fees not covered by my insurance company. I hereby
authorize the release of any medical information necessary to file a claim with my insurance
company. In the event that my account is turned over to a collection agency, I understand and
agree that I will be responsible for any collection fees, attorney fees, court costs, or other fees
incurred by me.
________________________________________________
__________________________
Patient/Responsible Party Signature
Date
HIPAA NOTICE
I understand The Women’s Center, PC is in compliance with the laws and guidelines of the
HIPAA regulations. All services and records are confidential and private to protect the patient.
________________________________________________
___________________________
Patient Signature
Date
If the patient is a minor, it is mandatory by HIPAA for the patient to sign a consent form to release
information to a parent or any other guardian if related to the following:
Contraceptive Care and Counseling
•
Prenatal Care
•
Abortion
•
Sexually Transmitted Diseases
•
HIV/AIDS
•
Substance Abuse
•
Emergency Care
•

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