Patient Forms

Please bring the patient forms with you on the day of your appointment.

Please complete and submit the New Patient Forms before your appointment. If you are a returning patient, you need to resubmit the forms before each appointment.

download new patient forms

Patient Privacy Statement

Private Insurance

You must provide private insurance information 24-48 hours prior to your appointment. You may call our office before your appointment to see what is covered.

We are providers of Maryland Medicaid.

We are providers of Blue Cross Blue Shield, Aetna, Cigna, Carefirst.

We are NOT providers of Allegiance, Anthem Blue Cross Blue Shield, Health Keepers, Highmark, United Healthcare, and federal insurance plans.

You will need to bring a photo ID and your health insurance card to your appointment. Any other payments can be made by cash or credit card.

Insurance Verification

We accept most pre-verified insurances to cover abortion services in all of our facilities. All of our facilities accept Maryland Medicaid. If your insurance is through an employee of the federal government, it will not cover abortion services. If you do not have insurance or your insurance does not cover the procedure, we work with local funding programs to assist with costs.

Insurance Verification Form: Patients may fill out their insurance information for prior verification. Insurance information must be received more than 24 hours before a scheduled appointment to be verified by the appointment time.

Funding Assistance

Programs designed to assist patients with no insurance or other means to pay for their care with supplemental financial support. You have no obligation to repay any grants made for you.

Assistance programs are phone-operated and you must call directly to the service.

These programs have our information and will send your pledge directly to us.

You may receive support from more than one funding program.

Other funding programs exist and your case manager may refer you to additional funding services which are accepted on a case-by-case basis.

Call us 301-251-9124 (Rockville), 301-733-2400 (Hagerstown), OR 410-788-4400 (Baltimore) in advance if you are receiving other funding so we can ensure it is accepted.