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Your Full Name
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First Name
Last Name
What are you dealing with?
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Pain
Leakage
Constipation or other bowel issue
Pregnancy concern
Birth Healing concern
Prolapse
Post-Surgery Healing
Other
Please be as specific as possible. We are required to include a diagnosis in the Good Faith Estimate
If you have received a diagnosis for this problem, please include it here
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What Does It STOP You From Doing?
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What Is Concerning You The Most?
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The pain I have
This is embarrassing
How this is affecting my workout performance or activity level
Not knowing what's wrong
This is affecting my sex life
Want to avoid surgery or medications
No signs of improvement yet
Fear that my condition may get worse
Other
What Is Your Insurance Coverage?
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Blue Cross Blue Shield
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Medicare B
Medicare Advantage
VA Benefits
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What is your Date of Birth?
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Month
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Day
Year
Date
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We will send you your written Good Faith Estimate within 3 working days.
Best E-mail
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Street Address
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