To insure that you receive your full insurance benefits, please answer the following questions. If you are unsure of the answers, use your insurance policy book, contact the insurance department at work or call the number on your card. (*Get the name and number of anyone you talk to!) This information is needed to deal with your insurance company. It is also important that you bring your insurance card(s) when you come for your visit. If you have questions about this form my office will help you when you arrive.

If you have insurance that requires us to file (usually a PPO, POS, or HMO policy), please answer all the questions below. If you plan to file for the doctor's services yourself (traditional insurance) answer only down to the double line. If you have two insurances, please notify the receptionist.

Name of Insurance Carrier _____________________ Insurance Network _______________________

Phone number of Carrier (_____) ________________ Precertification# (_____)___________________

Please fill out the information below on the primary policy holder. This may be a spouse, parent or you.

Name ______________________________ DOB _____________ Soc. Sec.# __________________

Address _______________________________ City ________________ State ____ Zip __________

Home # (______) _________________________ Work # (______) __________________________

Employer ________________________ Address _________________________________________

Group no. _________________ Policy no.___________________ ID/Badge no. ________________
Is there a secondary insurance? Yes No Will it pay what the primary insurance doesn’t? Yes No ________________________________________________________________________________

Are "well woman" exams (i.e. routine yearly no problem exams) covered under your plan? Yes No

Are Pap smears and labs covered as preventive medicine? Yes No

Does the policy cover "illness visits" (i.e. if a diagnosis is given or a problem treated)? Yes No

Can you be seen more than once in a year for this same problem? Yes No

Is a referral needed from a primary care MD (i.e. P.C.P.) for you to see an OB-GYN? Yes No

If so, what is your initial referral number? ________________

Does the plan have a co-pay to the doctor? Yes No If so, what amount $ _____________

Is there a deductible that must be met before you just have to pay a co-payment? Yes No

Is there a co-pay for well woman visits? Yes No Is there a co-pay for illness visits? Yes No

Is there a separate co-pay for lab or office procedures? Yes No