Thank you for scheduling your well woman exam today. A “well woman exam” is considered a preventative or wellness visit. This visit will address preventative health only and is not meant to diagnose or treat problems.

If your provider addresses and/or treats other health issues at this visit that are new or chronic in nature instead of scheduling you for a follow up or sick visit, your health insurance company may assess an additional patient liability for those services. Although most insurance plans include benefits for one preventative health visit, some do not. If you have any doubts, please check with your insurance plan.

If you need further explanation about incurring additional fees for services provided during your visit today, please discuss your concerns with your provider.

I acknowledge that I have read this notice prior to being seen and I understand that depending on the issues addressed or treated during today’s visit, additional charges may apply.