Forms For new & existing patients


Patient Forms

Please download, print and complete BOTH the New Patient Registration Form AND the New Patient Medical History Form below and bring the documents with you to your first appointment along with your medical insurance card and photo ID. If you are unable or need assistance, we ask that you please arrive at our office 30 minutes prior to your scheduled appointment time.

REQUIRED FORMS FOR NEW PATIENTS

New Patient Registration Form

Patient Medical History and Physical Form

Existing Patient Forms

If this is your first visit in the new calendar year, you have had a change of address or changes to your insurance since your last visit, please complete the forms below and bring it with you to your appointment so that we can update your medical records.

Registration Forms


Medical Records Release

If you would like a copy of your medical records, please complete the Medical Records Release Form below.

Medical Records Release Form


Associated Brochure Downloads for Your Reference

Patient Rights and Responsibilities
HIPAA Notice of Privacy Practices
Partnership for Safety


Insurance & Payment

We accept most major health insurance plans, however it is your responsibility to contact your insurance carrier to verify coverage and benefits. Patients may be held financially responsible for payment of services should the insurance company deny responsibility. Be sure to bring your insurance card with you every time you visit GYN Surgical Specialists. Notify the front desk whenever your insurance coverage changes so that the medical staff can accurately maintain your important medical records.

Payment

Payment is due at the time of service. This includes copays, deductibles, co-insurance, outstanding balances, and services not covered by your insurance.

GYN Surgical Specialists accepts cash & checks, VISA and MasterCard.