WHS TeleMAB Scheduling

Women's Health Specialists mails abortion pills, in 2-5 days

We take Medi-Cal and other insurance. Medi-Cal pays 100% with a video visit.
Do you need an abortion? Do you prefer pills by mail?

We will mail you abortion pills if you qualify. Our clinics accept Medi-Cal and other types of insurance. You may not need to pay anything. If you don't have coverage, our fee is $250.

This form takes about 10 minutes to complete. You'll need to know your address for shipping, and your Medi-Cal number if you have one.

Here's how it works:
1. Answer 14 questions about your health and this pregnancy to qualify.
2. We figure out how you're going to pay.
3. You choose a 15 minute video visit, in the next 5 days, at a time that works for you.
4. After your visit, your abortion pills will be mailed to you.
Click Next to get started.
Date*

MonthDayYear
Date

Are you the person who will be taking the abortion pills?*

YesNo

This is a medical history form, and it must be filled out by the person actually taking the pills. Please share the link with the person who needs abortion pills-we want to help.

What state will your abortion pills be mailed to?*

We are sorry – unfortunately we are not yet able to serve people living in your state. Please check INeedAnA.com or AccessRJ.org to find another provider.

Have you done a pregnancy test?

Yes, it was positive. I'm pregnant.No, I haven't taken a pregnancy test.

WHS can only send abortion pills if you are pregnant.

Please take a pregnancy test.

If the test is positive, come back to complete this form. We want your visit to happen soon!

To order abortion pills for the future, go to PlanCPills.org and look for organizations that say “Get pills in advance.”

Let's talk.

Abortion pills may not be safe for you. But we can help.

Please chat with us here or call to schedule a procedure: 1-800-714-8151

Funding may be available toward the costs of the abortion and travel, if you need it.

Let's talk about this.

You must have the IUD removed (or remove it yourself) BEFORE you can take the abortion pills.

You must get an ultrasound, to make sure the pregnancy is in your uterus, before you take abortion pills.

We're happy to see you at any of our clinics for services before your abortion. Please call or chat here to schedule your visit: 1-800-714-8151

The chance of having a pregnancy outside the uterus (“tubal pregnancy”) is very high if you had an IUD at the time you got pregnant. Click here to learn about ectopic pregnancy and when to get help.

2 more steps: Let's figure out how far your pregnancy has progressed.
When was the first day of your last menstrual period?*

MonthDayYear
Gestational advancement per LMP
Have you had an ultrasound in this pregnancy?*

No, I have not had an ultrasound.Yes, I had an ultrasound. I am less than 11 weeks today.Yes, I had an ultrasound. I am 11 weeks or more today.

Please share the date of your ultrasound. How many weeks and days did the report say you were?

Any of these things can make it harder to figure out how pregnant you are, based on your last period.*

I am breast-feedingI was taking hormonal birth control (pills, patches, rings, shot) when I got pregnantMy last period was much lighter than normalMy periods are not regular -- sometimes more than a week early or lateNone of these things are true for me
Are you 100% sure you are less than 11 weeks pregnant right now?*

YesNot 100%

You need an ultrasound before you take the abortion pills, to make sure you can safely use them at home.

We're happy to see you at any of our clinics. Please call to schedule a visit: 1-800-714-8151. We will suggest options close to you if needed.

You can request funding to help the costs of services and travel, if needed.

WHS only mails pills if you are sure you are less than 11 weeks pregnant.

WHS only mails pills if you can confirm you are less than 11 weeks pregnant.

Taking abortion pills at over 12 weeks increases the risk of heavy bleeding, incomplete abortion, and needing emergency care.

We're happy to see you at any of our clinics. Please call or chat with us to schedule a visit: 1-800-714-8151

You may be able to get funding to help the costs of the abortion and travel, if needed.

How are you sure that you are less than 11 weeks pregnant today?*

I know exactly when I got pregnant and it was less than 9 weeks agoThe first day of my last period was less than 11 weeks agoI had a negative pregnancy test less than 7 weeks agoI had an ultrasound showing I am less than 11 weeks pregnantOther
Please explain how you know you are less than 11 weeks pregnant.
Anything else that you want your medical provider to know?

Last step: Your personal details

You can get pills by mail after a 15 minute video appointment. Please tell us who you are. We'll help you figure out how to pay. If you have Medi-Cal, your abortion is covered.
Name*

First NameLast Name
Phone Number*
We will text a link to your paperwork to this number.
Date of birth*

MonthDayYear
Email*
We send a link to your paperwork to this email address.
After my video visit, my pills should be shipped to this address (does not need to match insurance billing or credit card)*

Street Address

Street Address Line 2

CityState

Zip Code

Are you a patient of West County Health Center?*

YesNo

Let's figure out how you will pay.

After this step, you can schedule an appointment for a video visit.

Our clinics are open 8:30-5pm Monday-Friday. We usually have next-day video appointments.
The cost for telehealth abortion care is $250. We can take your payment online, or we bill insurance. Do you have insurance?.*

Yes, I have Medi-Cal.No, I don't have insurance. I want to request Medi-Cal. I live in California and will provide monthly household income and family size.Yes, I have health insurance that covers abortion by telehealth. I want my care billed to that policy. (We will contact you with your cost for this care.)Yes, I have insurance, but I don't want this care to be billed for privacy reasons. I will pay $250 for my care.No, I don't have insurance. I will pay $250 for my care.

I don't have insurance or Medi-Cal. I want to get Medi-Cal so this service is free. I understand that my appointment paperwork will include a document that I must sign, confirming my income, family size and California address.

These questions will help us help you get coverage.
How many people are in your household? *
Family that lives with you, sharing income and expenses.
What is your household's monthly income?*
For last month, including all cash sources of income

Please check the boxes to agree to Medi-Cal billing.*

I have Medi-Cal coverage.I understand that Medi-Cal will pay for this service at no cost to me.
My Medi-Cal number is:*
If you don't know it, please put your SSN and our billing team will search for your Medi-Cal number.

Yes, I have health insurance that covers abortion by telehealth. I want my care billed to my policy.*

I understand that many insurance policies don't pay for telehealth. Others only pay after you have met a deductible.I understand that the subscriber (person whose name the policy is in) will receive a statement in the mail about my care. This explanation of benefits will state that my insurance paid for my abortion.We will contact you with your cost for this visit. Please leave time for this process, and be prepared for us to collect payment (online or by phone) before your visit.
If you have insurance, we are happy to try to bill your policy. Your coverage may not pay for a telehealth abortion. Our staff will be glad to figure out what your insurance will pay for. If you'd prefer a clinic visit that your insurance pays for, we will make you one. Just chat with us or call us 1-800-714-8151.
Please upload a picture of your insurance card (front and back) to get us started on billing. If this is impossible, please fill in the fields below and we will do our best.

Is your insurance card in your phone? Take a screen shot.
Cancelof
Subscriber name on insurance card
Me, my parent, or my spouse is the policy holder
Insurance carrier name
Anthem, United, Blue Shield, Aetna, Cigna, etc
Insurance ID number
This may be a lot of numbers and letters, put down everything

Our staff will reach out to you to collect payment by phone.
Phone Number
Please enter a valid phone number.

Choose your 15 minute video visit time. You will get a text link to join your appointment.*
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Women's Health Specialists mails abortion pills, in 2-5 days