Patient Release and History Forms

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Hours & Appointments Medical Records
Billing & Insurance Patient Forms

To protect your privacy, Women First requires your authorization before 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

Transfer to Women First Consent Form
OB History Form
Authorization for Use of Protected Health Information
Notice of Privacy Practices

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.
  • 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.

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3900 Kresge Way, Louisville, KY 40207 | Appointment Line: 502.891.8788 | Main Office: 502.891.8700
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