Patient Forms & Policies


 

Patient Forms

In order for Providence Women’s Healthcare to provide excellent service to all our patients, we have formed a set of policies that we believe will allow us to excel at patient care and satisfaction. Please take a few moments to review our policies. If you have any questions or concerns about anything, please feel free to call us at 770-670-6170.

New Patient Forms

Before your upcoming appointment, please print out the below forms, fill them in and bring them with you to your visit. Having these forms done before your arrival, will assure that you are able to been seen as soon as possible. If you have any questions about these forms, please call our offices at 770-670-6170. You may also fax the completed forms to 770-670-6171.

New Patient Forms

If you are unable to view the New Patient Forms, download Adobe Reader to view them, click here.

Medical Release Form

We will be more than happy to release your medical records at any time. In order for us to do this, please fill out the below medical Release Form and return it to our office. For your convenience, you may also fax the form back to us at 770-670-6171. Please note, there may be a fee associated with this request, based on whether you paid the Optional Obstetrical Administrative Fee.

Medical Release Form

If you are unable to view the Medical Release Forms, download Adobe Reader to view them, click here.

 

Our Policies

Appointments

If you are unable to keep an appointment, please call as soon as possible to reschedule.

  • If you are more than 15 minutes late for your appointment, we will do our best to fit you into the schedule, but we may need to reschedule you.
  • If you do not cancel 24 Hours in advance of your appointment or do not show for an appointment without 24 Hour Notice, you will be charged $25 per visit.
  • In consideration of our other patients, please know that If you have three (3) or more no shows or cancellations without notice, we have the right to deny you further appointments.
Office Visit Payments

Payment is due at the time of service either in full if you are a self-pay patient, or as designated by your insurance plan. We are happy to accept Cash, MasterCard, Visa, American Express, Discover or Debit Card as payment for your services. If you have any questions about what your responsibilities may be, please call your insurance company at the phone number listed on the back of your card. If you have any questions about a particular bill you received from our offices, please call our Billing Manager at 770-853-3796. For Billing and Insurance Questions click here.

Prescription Refills

Please allow 48 hours for refills .

  • Please leave your name, date of birth and pharmacy name and number when calling for a prescription refill.
  • Please check your bottles early and call us before you are out of your medication.
  • Please check with your pharmacy at the end of the day. We will only call you if there is a problem filling your request. 
  • No prescriptions will be filled after hours
    Please note: We will not be able to refill a prescription that was not written from our office.
Messages

We will contact you within 24 hours. All calls after 3:00 pm will be returned the next business day.

  • Our providers and clinical staff cannot diagnose your symptoms over the phone. If you require a new prescription for symptoms you are experiencing, please be advised that you will need to schedule an appointment to see one of our providers. You may also be able to utilize our Telemedicine Appointments for certain medical problems or consultation.
  • If you call and leave us a message, there is no need to leave multiple messages throughout the day.
  • If you require a call back but it’s not an emergency, we will contact you by the end of the day.
Lab / Test Results

Our office will contact you with any ABNORMAL lab results and instruct you on appropriate follow up. Most test results are reported through the portal system with a message if follow up is necessary.

  • Please allow 7-10 business days for most pap and lab results.
  • If your results are not posted to your portal within 10 business days, please call us and our medical assistant will return your call within 48 hours.
  • However, If you want to know any test results, please call us, and our medical assistant will return your call within 48 hours.
  • Our labs are processed through LABCORP. It is your responsibility to inform us if your insurance requires a different laboratory.
Obstetrical Administrative Fee

There is an optional $75 Administrative Services Fee for obstetrical patients to cover all administrative services that are not covered by your insurance.
If you choose to not pay this optional fee:

  • There is a $35 fee per form for completion of all forms including disability, FMLA and health forms.
  • There is a $35 administrative fee for each requested copy of your medical records from our office.
Surgical Procedures

The patient will be charged a fee of $300.00 in the event that a surgical procedure which has been scheduled for the patient is cancelled without 72 business hour notice. Exceptions may be made on a case by case basis.

Medical Records

Your medical records and all information contained within, are strictly confidential. No information is given over the telephone or in writing without your written consent and authorization. Whether you want certain information released or your medical records transferred, you will need to fill out a records release form. Please allow us 5-7 business days to complete this request. Link to Medical Release Form.

Patient Refund

The following criteria must be met prior to issuing a patient refund. There should be no outstanding insurance claims or balances on any of the patient’s account. Refunds will be issued once all outstanding insurance claims have been paid and all office charges are current. Refunds will be issued once a month. For refund questions click here.

After Hour Emergencies / Answering Service

If you are experiencing a true life threatening emergency, please dial 911. If you are experiencing any post-op problems or need to speak with a provider immediately for an emergent situation, please call our office at 770-670-6170, and our On-Call Provider will call you back. Leave your best contact number at the time of your message. Please remember to remove all blocks from your telephone as the providers do block their personal numbers when returning calls.

If you are unable to reach our offices, please proceed directly to the Emergency or Labor and Delivery Room at your nearest hospital.

If your problem is not a medical emergency, please call back during office hours. Prescription refill requests will be handled only during office hours.

Referrals

Some insurance companies require referrals for you to see a specialist. If you are referred to a specialist by one of our providers, we will be happy to provide you with a referral. If you plan to see a specialist unrelated to your OB/GYN health, you must obtain the referral from your primary care doctor.

Our Locations

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