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.
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