My Gynecologist New Patient Info Pack

The forms listed in this packet include the following:

Insurance and Billing Sheet
Patient Information Sheet (Registration Information)
Permission for Treatment and Payment Procedures, Privacy Notice, Designated Relative Gynecologic History/Intake Sheet

It is very important that we receive these forms prior to your visit! If they are not returned complete one week before your appointment, it is possible that you will have to reschedule. Unlike some offices you may have visited in the past,

My Gynecologist generally runs on time. We can do this because of requirements like this.

Please fill in all blanks, whether or not they apply to you. We prefer that you fax the completed forms to 352-684-6888, or you can mail them to the office.

Other Forms:

Women With Medicare
Patient's Bill of Rights and Responsibilities
My Gynecologist, PA - Notice of Patient Privacy Practice
Fee Explanation
Consent to Release Records To My Gynecologist

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