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.

Patient's 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 (beta)*

ABORTION CARE (medication, procedural)

GYNECOLOGY (office visits, exams, contraception)

OPTIONS COUNSELING (pregnancy, abortion, contraception)

Please Indicate Your Payment Method*

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: 500 MB, 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)