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Mirena Information for Patients You have asked for information regarding: Mirena IUD If you have internet access, please visit the Mirena informational website @ www.mirena-us.com for common questions and answers. Under the tab "How Do I Get Mirena?" click on Healthcare Plan Coverage to download an important form to have available when you contact your insurance coverage when calling to check on your benefits. Please check with your insurance company to see if these services are covered and what your co-insurance amount is. Please record what your insurance company tells you and bring to our office at your appointment. If you wish to proceed with services, you will be asked to sign a waiver that if these services are not a covered benefit, you understand that you will be responsible for the payment. When you speak to your insurance company, these are the codes that you should use to inquire about coverage: Mirena IUD - CPT J7302 Cost for IUD 620.00 Mirena Insertion fee - CPT 58300 Cost 180.00 Mirena removal fee - CPT 58301 Cost 150.00 Your Mirena may be covered under the pharmacy benefits of your insurance plan and not medical benefits. If you choose to proceed, you may be required to prepay your co-pay to the Mirena company. The Mirena company may be contacted by calling 1-866-647-3646. You will need to inform us if this is how your Mirena is covered so that we can order and it will ship directly to us. Your insertion fee may not be a covered service if the Mirena qualifies under pharmacy benefits and not medical. Mirena can be ordered from the company and placed on a credit plan if not covered by your insurance plan. If interested, please ask for information on the 3 payment plans that are available. If you wish to use this method, we order the Mirena and the company ships it directly to us.

Gardasil Information for Patients

You have asked for information regarding: Gardasil Vaccine If you have internet access, please visit the Gardasil informational website @ www.gardasil.com Please check with your insurance company to see if these services are covered and what your co-insurance amount is. Please record what your insurance company tells you and bring to our office at your appointment. If you wish to proceed with services, you will be asked to sign a waiver that if these services are not a covered benefit, you understand that you will be responsible for the payment. When you speak to your insurance company, these are the codes that you should use to inquire about coverage: Gardasil Vaccine - CPT 90649 (series of 3) Cost 232.00 per dose (Total 696.00) Gardasil injection fee - CPT 90471 ( series of 3) Cost 24.00 per injection (Total 72.00) If these services are not a covered benefit, we request payment on day of service. We accept Master Card and Visa for payment of services if you wish to use this method of payment.

ESSURE Information for Patients You have asked for information regarding: ESSURE (Hysteroscopic Sterilization) If you have internet access, please visit the ESSURE informational website @ www.essure.com for common questions and answers. Click on "Is ESSURE Covered by My Insurance?" to download important information to have available when you contact your insurance company to check on your benefits and coverage. Please check with your insurance company to see if these services are covered and what your co-insurance amount is. Please record what your insurance company tells you and inform our office. When you speak to your insurance company, these are the codes that you should use to inquire about coverage: ESSURE -Diagnosis Code V25.2 Admission for Interruption of Fallopian Tubes ESSURE Hysteroscopic Sterilization - CPT 58565 HSG Testing ­ Diagnosis codes V67.09 Follow-up examination following other surgery V26.51 Tubal Ligation Status CPT codes 58340 Catheterization and introduction of saline or contrast material for saline infusion sonohysterography or hysterosalpingography 74740 Hysterosalpingography, radiologic supervision and interpretation 74740-26 Professional component

Please be aware this information is for the services rendered by your surgeon and for follow-up testing. There will be additional facility charges from the hospital, as well as the anesthesiologist.

Implanon Information for Patients You have asked for information regarding: Implanon Implantable Contraceptive If you have internet access, please visit the Implanon informational website @ www.implanon-usa.com for common questions and answers. Under the tab "Is Implanon Right for Me?" click on "Determining your Health Plan Coverage" (this is on the left hand side). This gives you the information you will need when you call your insurance. Please check with you insurance company to see if these services are covered and what your co-insurance amount is. Please record with whom you spoke with & what your insurance company tells you and bring to your appointment. If you wish to proceed with services, you will be asked to sign a waiver that if these services are not a covered benefit, you understand that you will be responsible for the payment. When you speak to your insurance company, these are the codes you should use to inquire about coverage: Implanon Implantable Contraceptive ­ CPT J7307 Cost for device - $900.00 Insertion Fee ­ CPT 11975 Cost - $313.00 Removal Fee ­ CPT 11976 Cost - $247.00 In the process, you will also need to find out if it is covered as a medical benefit or a pharmacy benefit. Typically, IMPLANON® is covered as a medical benefit. Medical benefits cover in-office procedures that include visits, lab work, medicines, or products that you might receive. If IMPLANON® is not covered as a medical benefit, it may be covered as a pharmacy benefit.

ParaGard® Information for Patients You have asked for information regarding: ParaGard® IUC If you have internet access, please visit the ParaGard® informational website @ www.paragard.com for common questions and answers. The ParaGard® IUC is a non-hormonal, copper contraceptive lasting up to ten years. Approved by the FDA in 1984, it has been available in the United States since 1988. Please check with your insurance company to see if these services are covered and what your co-insurance amount is. Please record what your insurance company tells you and bring to our office at your appointment. If you wish to proceed with services, you will be asked to sign a waiver that if these services are not a covered benefit, you understand that you will be responsible for the payment. When you speak to your insurance company, these are the codes that you should use to inquire about coverage: ParaGard® IUD - CPT J7300 Cost for IUD 594.00 ParaGard® Insertion fee - CPT 58300 Cost 180.00 ParaGard® removal fee - CPT 58301 Cost 150.00 Post-insertion ultrasound (pelvic) ­ CPT 76857 Post-insertion ultrasound (transvaginal) ­ CPT 76830 Your ParaGard® may be covered under the pharmacy benefits of your insurance plan and not medical benefits. If you choose to proceed, you may be required to pre-pay your co-pay to the Duramed Company. The Duramed Company may be contacted by calling 1-877-727-2427. You will need to inform us if this is how your ParaGard® is covered so that we can order and it will ship directly to us. Your insertion fee may not be a covered service if the ParaGard® qualifies under pharmacy benefits and not medical. ParaGard® can be ordered from the company and placed on a credit plan if not covered by your insurance plan. If interested, please read about the self-pay plan on the website. The device will be shipped directly to us.

Gynecological and Obstetrical (Greater than 12 Weeks Gestation) Ultrasound Instructions Two hours prior to your appointment, empty your bladder. Begin drinking 30 ounces of fluid and complete one hour prior to your appointment. Do not empty bladder. Come to the office for your appointment will full bladder.

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