Request An Appointment for abortion or gynecological care in Virginia

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Today's Date

Patient's Full Name*

First Last

Pronunciation

(optional)

Patient's Birthdate*

Patient's Age*

Please enter a number from 0 to 99.

First Day of Last Normal Period*

Preferred Method of Contact*

Phone

Patient's Mobile Phone Number*

Confirm Phone Number*

Home Address (we will never send anything unless requested).*

Street Address Address Line 2 City State ZIP Code

Patient's Email Address*

Enter Email Confirm Email

Are you comfortable speaking with our staff in English?*

Yes

What is your preferred language?

Select your appointment type*

ABORTION CARE (medication, procedural)

GYNECOLOGICAL SERVICES (LARC insertion, contraception options)

Select your appointment type*

ABORTION CARE (medication, procedural)

GYNECOLOGY (office visits, exams, contraception)

OPTIONS COUNSELING (pregnancy, abortion, contraception)

Please Indicate Your Payment Method (NOTE: MEDICAID WILL NOT COVER ABORTIONS)*

Private Pay

Insurance

Important Information About Insurance
We welcome patients with or without insurance. As a courtesy to our patients we can check your benefits prior to your appointment, and as a courtesy we can submit insurance claims on your behalf. We highly suggest that patients contact the customer care department listed on the back of their insurance card to verify coverage. Due to Federal and Virginia state laws, Insurance through Medicaid and other government programs (Medicare, Tricare, etc.) do not cover abortion services. As of July 1, 2023, Falls Church Healthcare Center works with the following Insurance providers: * AETNA (HMO, PPO, POS, EPO, HDHP, HSA, Coventry, Signature Administrators) * Anthem Blue Cross Blue Shield (HMO, PPO, POS, HDHP) * Anthem Healthkeepers (Note: Anthem Healthkeepers Plus does not cover abortion services) * Carefirst Blue Cross Blue Shield (HMO, PPO, Blue Choice Advantage, Blue Choice Plus, Administrators) * HealthSCOPE Benefits * Innovation Health If your health insurance does not cover your services, we may be able to help! Please let us know when we confirm your appointment, and we can work with you on financial assistance options..

Important Information About Insurance

We welcome patients with or without insurance. As a courtesy to our patients we can check your benefits prior to your appointment, and as a courtesy we can submit insurance claims on your behalf. We highly suggest that patients contact the customer care department listed on the back of their insurance card to verify coverage.

** Due to Federal and Virginia state laws, Insurance through Medicaid and other government programs (Medicare, Tricare, etc.) do not cover abortion services. **

As of July 1, 2023, Falls Church Healthcare Center works with the following Insurance providers:
* AETNA (HMO, PPO, POS, EPO, HDHP, HSA, Coventry, Signature Administrators)
* Anthem Blue Cross Blue Shield (HMO, PPO, POS, HDHP)
* Anthem Healthkeepers (Note: Anthem Healthkeepers Plus does not cover abortion services)
* Carefirst Blue Cross Blue Shield (HMO, PPO, Blue Choice Advantage, Blue Choice Plus, Administrators)
* HealthSCOPE Benefits
* Innovation Health

If your health insurance does not cover your services, we may be able to help! Please let us know when we confirm your appointment, and we can work with you on financial assistance options..

Who is the insurance policyholder?*

Policyholder Name*

First Last

Policyholder Date of Birth*

Insurance Provider*

Policy / Member ID #*

Group #*

Provider Benefits / Customer Service Phone Number (Located on back of card)*

Use this field to upload a copy or picture of your insurance card (front & back).

Drop files here or

Max. file size: 2 GB, Max. files: 2.

Will you need financial assistance?

Yes

Gynecological Care

Plase be aware that FCHC will be closed on Tuesday, July 4. We will not be providing Telehealth or in-person appointments on that day.

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What type of appointment are you making?*

If "other" gynecological visit, please describe.

Which type of contraception are you interested in?*

Contraception – Other (Please Specify)

Select your preferred day for your gynological careappointment*

Select your preferred day for your Nexplanon appointment*

Select your preferred day for your Depo Provera appointment*

Patient Notes & Medical Conditions

Gynecological Care (Beta)

(B) Select your preferred day for your gynecological care appointment*

(B) What type of appointment are you making?*

(B) If "other" gynecological visit, please describe.

(B) Which type of contraception are you interested in?*

(B) Contraception – Other (Please Specify)

Options Counseling (Beta)

(B) Which type of Counseling are you interested in?

(B) Select Day for your Options Counseling Appointment:*

Abortion Care

Plase be aware that FCHC will be closed on Tuesday, July 4. We will not be providing Telehealth or in-person appointments on that day.

Type of Abortion Care*

Approximately how many weeks has it been since your last menstrual period?*

You can calculate this by using our Pregnancy Calculator. (Opens in a new window)

Select your preferred day for your in-person appointment*

Approximately how many weeks has it been since your last menstrual period?*

You can calculate this by using our Pregnancy Calculator. (Opens in a new window)

Select your preferred day for your in-person appointment*

Appointments will take 2.5 to 3 hours.

Select your preferred day for your in-person appointment*

Appointments will take 3-4 hours.

Select your preferred day for your in-person appointment*

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Telehealth

For more information you can visit our Telehealth page here.

Select your preferred day for your TeleHealth appointment*

Preferred Date of Telehealth Appointment?

Abortion Care (Beta)

(B) Type of Abortion Care*

(B) Approximately how many weeks has it been since your last menstrual period?*

You can calculate this by using our Pregnancy Calculator. (Opens in a new window)

(B) (9) Select your preferred day for your in-person appointment*

Appointments will take 1.5 – 2 hours on weekdays; up to 3 hours on Saturdays.

(B) (11) Select your preferred day for your in-person appointment*

Appointments will take 1.5 – 2 hours on weekdays; up to 3 hours on Saturdays.

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Patient Notes

Patient Notes & Medical Conditions

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Section Break

How did you hear about us?*

Other (Please Specify)

SMS/Text Message Notification

FCHC (through its secure vendor texting service) can contact you by SMS text message. Texting may include appointment reminders and other care-related messages. Your phone number will never be released to outside parties. To opt-out of SMS text messages I may reply STOP at any time or provide written notice to FCHC.

Acknowledge SMS/Text Message Notification*

I acknowledge and understand that I can OPT OUT of SMS text messaging by replying STOP at any time or by providing written notice to FCHC.

Appointment Cancellation Policy

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, our appointments are in high demand, and when you do not call to cancel an appointment 24 hours prior it significantly limits our ability to make the appointment available for another patient. If an appointment is not cancelled at least 24 hours in advance you will be charged a thirty-five dollar ($35) fee; this will not be covered by your insurance company.

Appointment Cancellation Policy*

I have read and understand FCHC’s appointment cancellation policy.