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NOTICE OF NONCOVERAGE Your appointment today is for an Annual Well Women Preventive Care Exam A well woman preventive exam includes the following components: A discussion with your provider about your health history and reproductive health care needs Physical examination, including a weight and blood pressure check Clinical breast examination Pelvic examination Pap smear if your provider feels it is necessary or indicated by ACOG clinical guidelines Ordering of various tests depending on a woman’s age, risk factors for disease and clinical screening guidelines. Recent healthcare laws now provide Well Women Preventive Care Exams. This exam is covered by Insurance under preventive services in most cases. Understanding your specific insurance regarding coverage, copays and deductibles is your responsibility. Please understand that your visit today is intended for a well women exam without medical symptoms or concerns. Should you have a medical concerns that you would like to discuss with your provider today, it may not be covered under the preventive portion of your insurance coverage. We may ask you to schedule a return visit to treat and discuss your concerns, or depending on your circumstances and the provider’s schedule, we may be able to complete both your Annual Well Women Exam and your problem visit today. Please be aware that these are billed as two separate exams and you will be responsible for the additional charges associated with the problem visit not covered under the preventive care portion of your insurance coverage. I have read and understand the guidelines for Preventive Well Woman Exam and agree that I may be billed for medical exam and any testing that would result from that added service. Patient Name: ____________________________________ Date: ______________________________ Patient Signature:________________________________________________________________________