Demographic Form

Please correct the errors described below.

PATIENT INFORMATION

RESPONSIBLE PARTY INFORMATION (Different than above)

PRIMARY INSURANCE

SECONDARY INSURANCE (If applicable)

I certify that the information I have provided is correct and I authorize Capital Women’s Care to verify insurance coverage and benefits allowed in accordance with my insurance plan's coverage I authorize payments be made directly to Capital Women's Care for all medical insurance benefits which are payable under the terms of my insurance policy for services provided. I agree to pay any copayment, coinsurance, or deductible as required by my insurance for services provided to me or my dependent. I understand that I am responsible for knowing the terms of my insurance plan. Capital Women's Care may impose a no-show fee of $35 for appointments not canceled 24-hours in advance.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.

Loading...