Registration

Practice State*

Practice City*

Practice Location

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Alabama Health Plans*

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Arizona Health Plans*

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California Health Plans*

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Connecticut Health Plans*

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Florida Health Plans*

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Georgia Health Plans*

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Practice Name*

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I am going to Self-Pay for the IUD (Not Using Insurance)

Yes

Now we need some Registration information from you:

Name*

Age*

Date of Birth*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone Number*

Email address*

Medicaid*

Yes

We do not accept Medicaid, MCO's, or Medicare

I am going to Self-Pay for the IUD (Not Using Insurance)*

Yes

Which State is your Health Plan through?

Alabama Insurance Plans We Accept

Arizona Insurance Plans We Accept

California Insurance Plans We Accept

Connecticut Insurance Plans We Accept

Florida Insurance Plans We Accept

Georgia Insurance Plans We Accept

Illinois Insurance Plans We Accept

Indiana Insurance Plans We Accept

Iowa Insurance Plans We Accept

Kansas Insurance Plans We Accept

Kentucky Insurance Plans We Accept

Louisiana Insurance Plans We Accept

Michigan Insurance Plans We Accept

Mississippi Insurance Plans We Accept

Nebraska Insurance Plans We Accept

New Jersey Insurance Plans We Accept

New York Insurance Plans We Accept

North Carolina Insurance Plans We Accept

Nevada Insurance Plans We Accept

Ohio Insurance Plans We Accept

Pennsylvania Insurance Plans We Accept

South Carolina Insurance Plans We Accept

Tennessee Insurance Plans We Accept

Texas Insurance Plans We Accept

Washington Insurance Plans We Accept

West Virginia Insurance Plans We Accept

Wisconsin Insurance Plans We Accept

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Health Insurance Name*

Insurance Policy Number#*

IMPORTANT: We make every effort to verify that the office inserting your IUD/LARC ALSO ACCEPTS your INSURANCE HEALTH PLAN.
If for any reason the inserting office does not accept your insurance you have 2 options: 1. Pay the office $150 dollars for the IUD/LARC insertion. 2. Call us to schedule your IUD Insertion at another office.

Signature*

Date*

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Name

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Registration

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Registration

Registration

Contact Us

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Areas We Serve

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