Patient Release and History Forms

	About Your Visit		Lab Services
	Hours & Appointments		Medical Records
	Billing & Insurance		Patient Forms

Women First is please to provide these patient forms online, making it easy for you to give us the information we need for your care. The Patient History and Patient Demographic forms give us your medial history, applicable insurance, and emergency and contact information for our electronic medical records. We ask that you fill out both forms completely and forward those to our office by fax or mail at least two weeks prior to your first appointment. Our fax number is (502) 891-8752, and our mailing address is: Women First of Louisville, Baptist East Medical Pavilion, 3900 Kresge Way, Suite 30, Louisville, KY 40207.

To protect your privacy, Women First requires your authorization before receiving or releasing any of your previous medical records. Please use the Transfer to Women First Consent Form to request permission from your previous physician and/or radiology department to release your medical records and existing mammogram films to Women First for our use in your health care.

If you are authorizing Women First to release your medical records to another physician, please fill out the Authorization for Use of Protected Health Information Form and send it to our offices.

Patient Release and History Forms

EMR Patient History Form
EMR Patient Demographic Information Form
Transfer to Women First Consent Form
Authorization for Use of Protected Health Information
Credit Card Policy

Disability Claims & Forms

Disability & FLMA

Women First of Louisville charges an administrative fee for the completion of certain work-related documents presented by patients. These documents include Disability Insurance Benefits Forms, Family and Medical Leave Act (FMLA) forms and return to work forms. Typically your employer or insurance company requires these forms when a medical condition prevents you from reporting to work. A licensed medical professional must sign these documents verifying that the information is correct. In the event that you need Women First to complete one or more of these forms we will be happy to assist you. The fee for this service is $30.00 per medical condition.

Please follow these steps to ensure the timely completion of your forms:

Obtain a copy of the forms from your employer or insurance company. We do provide a complimentary standard disability claim form (available for download below) which most employers and insurance carriers accept. Please check first before using these to make sure your employer or insurance company will accept them.
Complete & sign all parts of the form that are to be completed by the employee.
Mail or drop off the form(s) at our office. Include a check payable to Women First of Louisville for $30.00 unless you have previously paid this fee.
Please allow 3 business days for completion.

Standard Gynecological Disability Claim Form
Standard Obstetrical Disability Claim Form

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