Patient Forms


 

Patient Forms

For your convenience, we have made several patient forms available to be downloaded and printed prior to your visit. By completing these forms in advance, you will help us to serve you in a more efficient manner.

In order to access the forms, you must have Adobe Acrobat Reader installed on your machine.  All new gynecological patients must fill out forms 1-5. Or download the following forms packet:

New GYN Patient Forms

All new pregnant/ob patients must fill out forms 1-6.  Or download the following form s packet:

New OB Patient Forms

 


Individual Patient Forms

Patient Registration Form

 

Protected Health Information Form

 

Health History Form

 

Patient Privacy Acknowledgement

 

Financial Policy

 

Family Genetic History Questionnaire

 

Notice to Patients With Medicaid Coverage

 

Release of Records

 

Wellstar Pre-Admission

 

Privacy Form

  

Medicare Patient Self Pay Fee Schedule

 


Billing

OB-GYN ASSOCIATES of MARIETTA is a division of ATLANTA WOMEN’S HEALTH GROUP (AWHG). All insurance claims will be billed and monitored by AWHG.  In addition, AWHG will send statements to patients showing account balances.  If you have questions regarding insurance claims, payments or account balances, please call the phone number on your account statement or the AWHG Central Billing Office at 678-891-6552.

All laboratory procedures are billed separately from your office visit. Please contact LabCorp, Quest or Phytest if you have billing questions as a result of a statement that you may have received from them.

 


Insurances

We participate with the following insurance plans:

•Aetna (HMO/PPO/POS/Aexcel & Aexcel Plus)
• Alliant Health Plans (HMO/Solocare and Simplecare (Exchange Products)
•Amerigroup (Obstetrics Only)
•Beechstreet
•Blue Cross Blue Shield (HMO/PPO/POS/PAR/SHBP/Anthem/Blue Direct/ Blue Open Access/Pathway Exchange Products)
•Champus
•Cigna (HMO/PPO/POS/EPO/Open Access Plus)
•Coventry (HMO/PPO/POS/ National Network/Coventry One HMO Exchange Products)
•First Health Network
•Harken Health (Tier 2 Only)
•Health One Alliance PPO
•Health Plan Select (Multiplan Only)
•Humana (HMO/PPO/POS/Open Access/Preferred Open Access/HMOX Exchange Products)
•LifeWell Health Plans
•Medicaid (Obstetrics Only)
•MDI Healthcare Solutions
•Multiplan
•NovaNet
•PHCS
•Tricare (Standard & Prime)
•United Healthcare (HMO/PPO/POS/Core/Navigate/Charter Network/Compass Exchange Products)
•Wellcare (Obstetrics Only)
•Wellstar Plans 




Please note that OB-GYN Associates, as an affiliate of Atlanta Women’s Health Group, is not contracted with Medicare or Medicare Advantage plans offered by other insurance carriers.  Medicare patients may still be seen by our practice but a waiver must be signed to indicate an acceptance that we will not bill Medicare. All services provided will be billed directly to the patient under our “Medicare Patient Self Pay Fee Schedule”. The Fee Schedule can be found on the Patient Forms page of the website.

Insurances Accepted

For any coverage-related questions, please contact our office.

Aetna
Alliant Health Plans
Amerigroup
Beechstreet
Blue Cross Blue Shield
Cigna
Coventry
First Health
Humana
Medicaid
Multiplan
PHCS
Tricare
United Healthcare
WellCare
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