What to Bring to Your Appointment

• Your insurance card
• Physician referral forms if required by insurance
• A list of current prescriptions and/or over-the-counter medications you are taking, including dose and frequency
• Pertinent information about your medical and surgical history
• Any recent x-rays or appropriate records you may have
• A valid driver's license
• The address and phone number of your pharmacy

Insurance and Payment Information

The Incontinence and Pelvic Support Institute is a provider for Medicare and most major insurance plans. We provide insurance billing. Anything not covered by insurance will be your responsibility.

We request payment at the time of your appointment for services that are not covered by insurance. Your insurance company may also require you to pay a co-payment at the time of your appointment. When necessary, our staff will work closely with patients who require a payment plan.

If you have any questions regarding which insurance plans we accept or any patient billing concerns, please call us at the phone number below. Questions regarding your coverage and benefits should be directed to your employer or insurance company.

Patient Forms

Please complete, and bring the following patient forms to your office visit:

• Patient Demographic Form [PDF]
• Financial Policy [PDF]
• Arbitration Letter [PDF]
• Notice of Privacy Practices [PDF]
• HIPAA Acknowledgement Form [PDF]
• HIPAA Confidential Communication Request [PDF]
• Advance Beneficiary Notice [PDF]

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