new patient

NEW PATIENT Intake Form- Click To Download PDF

Signature Form- Click To Download PDF

What To Bring

  • a driver's license or other current photo identification
  • a social security card if the social security number is not on the driver's license
  • current insurance card
  • social security number & date of birth of the policy holder of all insurance plans

Returning patients will need to provide current insurance information and we will verify/compare information and photo from the preceding visit(s).

Return Patient Intake Form- Click To Download PDF


Effective May 1, 2010, all physicians' offices are required by the Federal Government to comply with the “RED FLAG RULES”. This set of requirements was imposed because of the rising occurrence of patient identity theft.

In an effort to be diligent in protecting our patients, the Woman's Clinic considers the documentation required as you check in to be our best defense in the prevention of patient identity theft. We thank you in advance for understanding this and being prepared to provide us with the information.

What To Expect

  • Arrive fifteen minutes early
  • Sign in and have a seat
  • Front desk will call you to gather your information
  • Your photo will be taken to protect your medical security
  • You will be asked to turn in or fill out an intake form
  • Your copay will be collected
  • A nurse will then call you back to collect your medical information
  • You will see your provider
  • Any lab work or ultrasounds will be performed
  • Drop off any paperwork provided to you at our check-out desk
  • Make a return appointment if necessary

Financial Policy
In our attempt to provide the highest quality services for our patients, the Woman's Clinic will file an insurance claim with most insurance providers. We are not Tricare or TennCare participating providers. If your insurance requires a copay for a visit, you will be expected to pay as you register at the front desk for your appointment. Our patients are required to assign the insurance company payments directly to the Woman's Clinic for services rendered. If a problem were to arise with a claim, our staff will make every reasonable effort to resolve issues or misunderstandings. However, please remember that the contract for payment is between you and the insurance carrier and our staff is not responsible for settling disputes for non paid services. The patient account's responsible party is liable for charges not covered or denied by the insurance carrier. If our patient is not willing to assign the insurance benefits, the services provided will be rendered as self-pay and payment is to be made at the time of service. All self-pay patients are required to bring a minimum amount with them at the time of the appointment. The appointment representative will instruct the patient of the amount that will be required of them at the time of registration. All patient accounts are due and payable in full at the time of services unless suitable arrangements have otherwise been made with our credit department. Accounts with payment arrangements will receive a statement for the balance and payment is required each 30 days on the account to avoid collection activity. Past due accounts will receive a series of phone messages and/or letters. If payment is not received in a timely manner, the account will be reviewed for placement with outside collections and subject to fees incurred by the collection process. Remember, communication is the critical factor is maintaining a healthy financial relationship with our facility. We are more than willing to work with our patients toward reaching a mutually agreeable account resolution.

No Show Policy
We realize your time is valuable and so is the time for our providers. Patients who consistently schedule appointments then do not come in or call to cancel/reschedule will be charged a $25.00 "no show fee" after two occurrences. Rescheduling these appointments for other patients who are wanting to come in earlier allows the Woman’s Clinic to keep “full” or “complete” schedules for our providers.

Insurance
The Woman's Clinic participates with the following insurance companies and PPO Networks. Some PPO networks contract with multiple insurance companies, so if your insurance company is not listed, please check your insurance card to see if a PPO network is listed or call your insurance company to see if our doctors participate with your plan. We do NOT participate with any HMO type plans.

  • Aetna POS and PPO plans
  • Blue Cross Blue Shield-Network S, Network P and BlueAdvantage Medicare plan (If you have CoverTennessee and your card has "Network S" on it, we will take that but not "Network V")
  • Cigna Great West-now part of Cigna
  • Medicare, and Medicare PFFS plans. If you have non-traditional Medicare and your card has the letters "PFFS", we do participate.
  • Health Partners/TN Healthcare
  • PHCS Multiplan
  • Coventry
  • First Health
  • ChoiceCare
  • Beech Street
  • CCN
  • PPO Next
  • USA MCO
  • Three Rivers Provider Network discount plan (TRPN)
  • United Healthcare (eff 6/1/10)
  • Principal Edge Network

We will file with any insurance plan, except TennCare, for a decision on a claim; however, the ultimate responsibility for payment rests with the patient. Your insurance coverage is a contract between you and your insurance carrier and the policy holder always has the best access to coverage and policy details. Always self-verify if you are unsure. There are constant changes in the insurance industry and we are not always aware of these immediately.

The Woman's Clinic's preferred laboratory is LabCorp. We also use Medical Center Laboratory which is connected with the West Tennessee Healthcare system. We do not have any contracts outside of these for lab services.