Tampa: The Centers For Vulvovaginal Disorders Patient Registration

The Centers for Vulvovaginal Disorders: Tampa

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* 1. Date of scheduled appointment

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* 2. Select the location of your scheduled appointment:

3216 West Azeele St
Tampa Florida 33609

Other (please specify)

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* 3. Full Name

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* 4. Date of Birth

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* 5. What are your pronouns?

she/her/hers

he/him/his

they/them/theirs

Prefer not to answer

Other (please specify)

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* 6. Home/Mailing Address

Street Name:

City:

State:

Zipcode:

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* 7. Cell Phone Number (enter NA in none)

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* 8. Home Phone Number (enter NA if none)

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* 9. Work Phone Number (enter NA if none)

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* 10. Email Address (enter NA if none)

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* 11. Preferred method of communication

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* 12. Emergency Contact - name and relationship

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* 13. Emergency Contact - phone number

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* 14. Employer (enter NA if none)

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* 15. Occupation (enter NA if none)

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* 16. IMPORTANT POLICIES OF THE CENTERS JILL KRAPF, MD

Your First Appointment:
New patient appointments are approximately 80 minutes, but we ask that you set aside 2 hours in the event that your appointment requires more time. If English is not your primary language, we advise you to bring someone with you to translate and assist you throughout the appointment, as needed. Please contact our website for our address and directions to our office: www.jillkrapfmd.com.

Your Providers and Care Team:
Our providers are considered world-renowned experts on vulvar disease. As such, we frequently have visiting health care providers shadowing our physicians to learn from us and spread awareness. You reserve the right to refuse to allow them to be present during your visit. Please note that some of our providers have a scribe present throughout the entire appointment to detail your comprehensive visit. These scribes are employees of Jill Krapf, MD. Our scribes handle the note-taking and box-ticking of modern-day medicine, allowing our providers to have more face-to-face time with the patient.

Required Paperwork:
The Vulvar Pain Questionnaire AND Registration form must be completed no later than 1 week prior to the visit. Our providers will not consult with or examine you unless you have completed these medical intake forms. Both documents can be found on the main CVVD website at www.cvvd.org/contact, which is also linked through www.jillkrapfmd.com. Your provider will review the answers to your questionnaire and may ask additional questions during your appointment. This confidential questionnaire will become part of your medical record. This data may be tabulated (without your name) in the course of research studies to learn which factors seem most important in evaluating other patients with these similar problems. In addition, you may have photographs of your genitalia taken during this visit; you may refuse consent.

The Centers for Vulvovaginal Disorders including the Washington, DC and New York locations share an Electronic Medical Record with Jill Krapf MD at the Tampa, Florida office. You are giving permission for your providers and care team to access these records as applicable to your patient care across the offices.

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* 17. PAYMENT POLICY
Our policy is that payment is to be made at the time services are rendered. Whether or not your insurance pays in full, a portion or nothing at all for services is a matter between you and your insurance carrier. Payment is accepted in the form of cash, check, money order, or credit card. The patient agrees to pay a $250 cancellation fee if the appointment is not canceled or rescheduled 1 week prior to your appointment time. To complete scheduling, we require a form of payment on file. There will be no charges made until after your appointment, unless the cancellation fee goes into effect.
*We do not accept CareCredit.

CANCELLATION POLICY:
We at Dr. Krapf's office value your time and understand that unforeseen circumstances may arise that could force you to postpone or cancel your appointment. We Kindly request you review our cancellation policy to ensure a seamless experience for all of our patients.

1. We require at least 1 week notice if you need to cancel or reschedule your new patient appointment. This allows us to allocate this time to another patient.
2. If you cancel your appointment less than 1 week before it is scheduled to take place, or do not show up for your scheduled appointment, you will be subject to a cancellation fee of $250.

Please note: Jill Krapf MD is not responsible for any costs that you incur as a result of the cancellation or rescheduling of your appointment including (but not limited to) flight cancellation/change fees, hotel cancellation/change fees, or lost wages. As such, we STRONGLY encourage you to get FULLY REFUNDABLE tickets and/or reservations.

Insurance and Payment Policy:
Jill Krapf MD offers patients comprehensive health care which
limits our ability to work within the limitations of the health insurance industry. Due to this, we do not accept insurance, Medicaid, Medicare, or Tricare nor do we accept assignment, file, or coordinate insurance reimbursements. We will provide you with an itemized receipt that you may use to file with your claim for reimbursement.

Appointment Cost:
The cost for a new patient appointment is $1800 for new patients seeing Dr.
Jill Krapf at her Tampa, Florida office. Payment, in full, is required at the time of service. We accept all major credit cards, cash, and checks (from a US banking institution).

Labwork:**
All labwork performed during the visit will be sent to Quest or Labcorp (further referenced as "the lab") for processing. We will provide them with your insurance information so that they can process/bill your labwork through your insurance company. If you are uninsured or there is any gap in coverage for labwork performed, the lab will contact you directly to collect payment.

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* 18. In order to secure your new patient appointment, and as part of our cancellation policy, we require a credit card on file. 1. Your credit card information will be stored securely, and will only be charged if the cancellation policy comes into effect. 2. If you cancel your new patient appointment less than 1 week in advance, or fail to show up for your scheduled appointment, we reserve the right to charge your credit card the $250 cancellation fee. 3. No charges will be made to your credit card without your consent. Please understand that our cancelation policy is in place to provide the best care possible to you and all of our valued patients. We appreciate your understanding and cooperation.

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* 19. Credit Card Information To Keep on File

CC #

Exp. Date

Security Code

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* 20. ***Please provide your insurance information in the space below (enter N/A if none) OR upload your insurance card (skip to questions 19 and 20). This information provided to our labs for specimen processing.

Insurance Carrier name

Member ID

Group number

Insurance claims address

Phone number

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* 21. Please upload an image of your insurance card. (FRONT).

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 22. Please upload an image of your insurance card. (BACK)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 23. By typing your name below, you are acknowledging that you have fully read and completely understand Dr. Jill Krapf's office and payment policies, as discussed above.