Where compassionate care, uniqueness of experience and outstanding medical practices blend together, giving every woman, the exceptional healthcare she deserves.
Johns Creek/Alpharetta
4035 Johns Creek Parkway
Suite A
Suwanee GA 30024
Atlanta/Dunwoody
2398 Mount Vernon Rd.
Ste 150
Atlanta, GA 30338
Roswell
1300 Upper Hembree Road
Building 100, Suite D
Roswell GA 30076
Contact Us at (770) 670-6170
 
Patient Forms - Providence Women's Health Care

Patient Forms

New Patient Form

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.

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

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:

Billing & Insurance Concerns

 

Verification

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. Please note: We will not be able to refill a prescription that was not written from our office.

 

Messages

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.
  • 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.

  • If you do not hear from us, your results are within normal range and no follow-up is necessary.
  • However, If you want to know any test results, please call us, and our medical assistant will return your call within 48 hours.
  • Please allow 7-10 business days for most pap and lab results.
  • Our labs are processed through LABCORP. It is your responsibility to inform us if your insurance requires a different laboratory.

Obsterical 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.

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:

Billing & Insurance Concerns

 

Verification

After Hours 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.

Your Protected Health Information

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can
get access to this information.  Please review it carefully.

If you have any questions about this notice please contact our office at 770-670-6170 and ask to speak with the Office Manager.

Notice of Privacy Policies (HIPPA)

At Providence Women’s Healthcare we are committed to treating and using protected health information about you responsibly. This Notice of Health Information Practices describes personal information we collect from you, and how and when we use or disclose that information. It also describes you rights as they relate to your protected health information. This notice effective 04/01/2003 and applies to all protected health information by federal regulations.

Understanding Your Health Record/Information

Each time you contact Providence Women’s Healthcare a record of your contact is made. Typically, this contains symptoms, diagnosis, treatment and plan for future care. It also contains a description of the equipment or supplies we provided for you. The information is often referred to as health or medical record and serves as a:

  • Basis for planning your care and treatment
  • Means of communication among the many health professionals who contribute to your care
  • Legal document describing the care you received
  • Means by which you or a third party payer can verify that services billed were actually provided
  • A tool in which we can assess and continually work to improve the care we render and outcomes we achieve

Understanding what is in your record and how your health information is used to help you to: ensure its accuracy, better understand, who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.

Your Health Information Rights

Your health record is the physical property of Providence Women’s Healthcare, but the information it contains belongs to you. You have the right to:

  • Obtain a paper copy of this notice of information practices upon request
  • Inspect a copy of your health record as provided for in CFR 164.524
  • Request amendment to your health record as provided in 45 CFR 164.528
  • Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528
  • Request communications of your health information by alternative locations
  • Request a restriction on certain uses and disclosures of your health information as provided by 45 CFR 164.522, and revoke authorization to use or disclose health information except to the extent that action has already been taken.

Our Responsibilities

Providence Women’s Healthcare is required to:

  • Maintain the privacy of your health information
  • Provide you with this notice as to our legal duties and privacy with respect to information we collected and maintain about you
  • Abide by the terms of this notice
  • Notify you if we are unable to agree to a requested restriction, and accommodate reasonable requests you may have to communicate
    health information be alternative means or at alternative locations

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you have supplied us with.

 We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue using or disclosing your health information after we have received a written revocation of the authorization according to the procedures included in this authorization.

For More Information or to Report a Problem

If you have any questions and/or would like any additional information, you may contact the office manager at Providence Women’s Healthcare at (770) 670-6170.

If you believe your privacy rights have been violated, you can file a complaint with the privacy officer or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filling a complaint with either the Privacy Officer or the Office of Civil Rights. The address for the OCR is:

Office of Civil Rights: U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, HHH Building , Washington, D.C. 20201

Examples of Disclosure for Treatment, Payment and Health Options

For Treatment
Information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your provider will document in your record his/her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment.For Payment
A bill may be sent to your or a third-party payer.   The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedure and supplies used.For Regular Health Operations
Members of the medical staff may use information in your health record to assess the care and outcomes in your case and other cases like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and services we provide.For Business Associates
There are some services provided in our organization through contact with business associates. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered to protect your health information however, we require our business associate to appropriately safeguard your information.For Workers’ Compensation
We may disclose health information to the extent authorized by and the extent necessary to comply with laws relating to workers compensation or other similar programs established by lawFor Public Health
As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.For Law Enforcement
We may disclose information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

 

 

 

 
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