Download Notice of Noncoverage

NOTICE OF NONCOVERAGE
Your appointment today is for an Annual Well Women Preventive Care Exam
A well woman preventive exam includes the following components:
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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:________________________________________________________________________