Forms and Policies for Women’s Clinic
To download any of the forms below, simply click the link and then download/print.
- Medical Information Release Form
- Authorization of Use and Disclosure of Protected Health Information
- Authorization for Release of Information & Assignment of Benefits for Non-Medicare Patients
- Informed Consent for Telemedicine Services
- Patient Instruction for Colposcopy
- Bowel Preparation Instructions for Surgery
- Post Op Instructions
- Highmark Blue Cross Blue Shield
- Independence Blue Cros
- United Healthcare
- Cigna HealthSpring
- Gateway Health
- MultiPlan- PHCS
- Tricare standad
Frequently used Terms by Insurance Companies:
- Benefit: Amount of money your insurance plan pays for the health care services you receive.
- Billed Charges: Billed charges mean the total charges billed by a healthcare service provider. It shows the gross billed or retail billed price of services and does not represent the amount paid by the insurance or billed by the provider
- Claim: This is another word for a health care bill. It is sent to your insurance plan and it list out all of the services you received.
- Coinsurance: Some insurance plans cover a percentage of the cost of your care. For example, if your plan has 10% coinsurance for a service that cost $50, your insurance plan will pay $45 dollars and you will pay $5.
- Copay: A fixed amount paid by a patient for a covered service. Some insurance plans cover certain types of care at a set rate- also called a copay. For example your plan may charge $25 per doctor visit or $50 dollars for each day a patient is an inpatient in the hospital.
- Deductible: A set amount you have to pay every year before your health insurance company starts paying. For example, if your health care service costs $5,000 and your plans annual deductible is $3,000, once you have paid that $3,000, your insurance plan will pay all or part of the remaining $2,000 (depending on what type of coverage your plan has). Most insurance plans have to cover some services (like annual well visits), regardless if you have met your annual deductible or not. PLEASE NOTE: Patients who come for annual well women visits and discuss issues not considered covered under the annual may be subject to other outstanding charges by the payor.
- Fee Schedule: List of charges for health care services. Insurance plans publish fee schedule lists representing the maximum charges (or prices) they will reimburse for the same services. In many instances, the reimbursement amount offered by insurance plans is less than what is charged by health care providers.
- Premium: The amount that must be paid to the insurance plan to maintain the desired insurance plan coverage.