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.
Along with the completed forms, you may scan your insurance card(s) and Identification and Fax all documents to (928) 771-0920 or email Frontdeskpwc@cableone.net or drop off forms prior to your appointment at either of our locations.
Financial Policy & Patient Registration Form
Patient Consent Detailed Information
The deductible is the total amount a patient must pay out of pocket before his or her insurance starts to pay. For example, if a patient’s deductible is $1,500, then his or her insurance won’t pay anything until that patient has spent $1,500 on services that are subject to the deductible (it’s important to note that not all services apply to the deductible). Furthermore, even after a patient meets his or her deductible, that patient may still owe a copay or coinsurance amount for each visit.
• Prescott Women's Clinic patients are asked to be prepared to meet their insurance (contractual) commitment at every visit.
A copay is a fixed amount that a patient must pay for a covered service—as determined by his or her health plan. Usually, copays vary for different plans and types of services. Patients typically pay their copays at the time of service—and, because this amount is fixed, they’ll pay the same amount regardless of the visit length.
• Prescott Women's Clinic patients are asked to meet their insurance (contractual) commitment and be prepared to pay their co-pay at every visit.
This type of out-of-pocket payment is calculated as a percent of the total allowed amount for a particular service. Thus, it’s the patient’s share of the total cost. For example, let’s say:
•the insurance plan’s allowed amount for an office visit is $200;
•the patient has already met his or her deductible; and
•he or she is responsible for a 20% coinsurance.
In this scenario, the patient would owe $40 at the time of service, and the insurance company would pay the rest of the allowed amount for that visit. Coinsurance amounts may vary from visit to visit—depending on what services the patient receives.
• Prescott Women's Clinic reminds our patients it is important for you to understand your health insurance benefits, co-pays, deductibles, and co-insurance to meet your contractual obligation as defined by your health insurance company.
Please feel free to call ahead (928) 778-4300 Prescott Women's Clinic will take payments over the phone via bank card or at the time of service via bank card or cash.