Abortion Pill - FPA Family Planning Associates Medical Group

Patient First Name*

Patient Last Name*

Patient Date of Birth*

YESNO

Contact Information

If we are unable to reach you by telephone we will text you and ask that you call us when it is convenient for you. Unfortunately, due to an extremely high volume of online appointment requests we are unable to schedule and confirm visits via email only right now. We must speak with you directly. We still encourage you complete the online appointment request so that we can enter your information into our scheduling system. This will make the scheduling process faster for you.

Patient's Phone Number*

Your Zip Code*

YESNO

Last normal period date*

What date did your period start?

Ultrasound results / When did you become pregnant?*

Please provide any information you have regarding the length of your pregnancy.

YESNO

Preferred Appointment Day*

Preferred Time

Medical conditions & information

Do you have any medical conditions or problems? Do you take any medications? Have you ever had a surgery or spent time hospitalized?

Private Insurance Info

Insurance Plan Phone Number

Insurance ID

Insurance Group Number

Subscriber Name & DOB (If Parent/Spouse)

We will contact you by phone, text or email about your insurance coverage for the procedure you have requested. Keep in mind that you may be responsible for some payment if your insurance requires you to pay a deductible, copay or co-insurance amount. If you have an HMO insurance plan, you will need to get a written referral from your doctor. Please contact our insurance staff if you are having a hard time getting a referral for care from your physician.

Illinois Medicaid Recipient ID Number

Please provide your Illinois Medicaid Recipient ID so we can check your coverage, before your visit. If you are currently enrolled in Illinois Medicaid please bring in your picture ID and Medicaid card and we will be able to provide abortion care for you at NO COST. You will not have to pay anything for care related to your abortion including sedation, medications, lab testing, ultrasound, or RhoGAM if you have a negative blood type. You can also email the document(s) to FPA before your visit. The email address is: medicaid@fpachicago.com. For more information, click here.

Is there anything you would like our staff to know?

We have reduced fees for patients who are uninsured. You may be eligible for financial assistance. Please let us know if you need help with your payment. If you have already been in contact with an abortion fund, and they have pledged funds on your behalf, please let our staff know.

If you have applied for Illinois Medicaid coverage or plan to apply, we can provide abortion services at no cost to you once your application is approved. If you have not applied for coverage yet, go to www.abe.illinois.gov to apply TODAY. Remember: 1. Say you are pregnant 2. Ask that your coverage begin at the first of this month, or earlier if you have any other past medical bills 3. DO NOT WAIT start your application today 4. Write down and save all of your login information Call 312-707-8988 with questions. If you need urgent coverage, you can visit a Medicaid Presumptive Eligibility Provider and leave their office with coverage. Most hospitals are MPE providers and Erie Family Health Center is an MPE provider. You can call them at 312-666-3494 or 847-666-3494 if you live in the suburbs of Chicago. Once you are approved – you pay nothing for abortion services. For more information, or to access a link to the website where you can apply for coverage, click here.

How did you hear about us?

Please specify

Email address*

Is there anything you would like our staff to know?*

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