Forms & Policies


To schedule an appointment, please call us during office hours. The receptionist will ask you to explain the nature of your visit, so that we can give you the appropriate priority and amount of time.

What is NOT included in a Well Woman / Annual Exam?

If an abnormality is encountered or a pre-existing problem is addressed in the process of performing a Well Woman/Annual Exam and requires additional time, ordering of tests, or diagnostic studies, it will be coded and billed as an additional visit and may require a co-pay or deductible at checkout.

Patient Forms & Information

We know that your time is important and we want to ensure that we are our prompt for your appointment. So we can better serve you, we ask that you create a patient portal account to complete your paperwork on-line at least two days prior to your appointment. This will enable our nurses to establish or update your medical chart. If you have not already received your personal invitation to sign up for the portal please contact our office and we will be happy to send you one. Failure to complete your paperwork prior to your appointment, will result in a delay in seeing the provider.

Medical Records Request

Kennesaw Gynecology requires a written authorization to release your medical records to you or a third party via fax, email, or in paper format. The process is in place to protect our private health information. One copy of your records will be provided at no charge. A $35.00 administrative fee will be assessed after the 1st copy.

To request your medical records, please follow the steps below:

  1. Download and print
  2. Authorization to Release Medical Records
  3. Make sure the patient or authorized requestor (if not the patient) signs the form.
  4. Submit your completed Medical Records Release form along with a copy of the requestor’s photo ID via one of the below methods:
  5. Fax the completed form and photo ID to 770-627-5228
  6. Email the form and copy of photo ID to
  7. Mail the completed form and copy of photo ID to:Kennesaw Gynecology
    1595 Kennesaw Due West Road NW
    Suite 100
    Kennesaw, GA 30152

Click here to download our Medical Record Request form.

Insurance Information

We recommend that you contact your insurance company to verify our practice’s participation with your insurance plan.

We currently accept:

  • Aetna
  • BCBS
  • Cigna
  • Oscar
  • Tricare Prime
  • Tricare Standard
  • Humana
  • Medicare
  • Medicare Advantage plans
  • Sonder
  • Ambetter
  • Pruitt
  • Multiplan
  • Tricare
  • Caresource
  • Clover
  • United healthcare

Copays, Deductibles, and Co-Insurance

Payment is due in full at the time of service or as designated by your insurance plan.

Surgery patients will be responsible for paying their deductibles and/or co-insurance prior to the surgery being performed. These are usually paid at your pre-op visit. Our office will contact you prior to your preop date to inform you of your amount due.

Patients who do not have a designated copay will be responsible for paying either the deductible and/or co-insurance at the time services are rendered. These amounts will be calculated at the time you check in and determined by your charges for the day.

Have insurance and billing related questions?

We are happy to answer your insurance and billing related questions. Please call 470-308-3664 or email us at

Self-Pay Rates

For those who do not have health insurance, who are underinsured, or who wish to pay without filing through their insurance company, need to be aware that it is difficult to determine the true cost of healthcare services. Kennesaw Gynecology offers discounted rates for patients paying out-of-pocket. We expect that payment be made in full at the time of service. Please note: If you choose to use our self-pay option, no insurance will be filed.

Cancellation Policy

If you need to cancel your appointment, please call the office during business hours and allow at least 24 hours’ notice, so that we can offer your appointment to other patients on our waiting list. If you cancel your appointment on the scheduled day, there will be a no-show fee that will have to be paid at your next re-scheduled appointment. If you cancel your appointment on the scheduled day, there will be a no-show fee that will have to be paid at your next rescheduled appointment. Patients who fail to cancel their appointments 24 hours prior to their appointment, will be charged as follows:

  • New Patients  $100
  • Existing Patients  $75
  • Office Procedure  $150
  • Ultrasound  $250

We recognize that your time is valuable, and we make every effort to run on time. Occasionally emergencies or patients require a little more time, and these cause scheduling delays beyond our control. We apologize if we keep you waiting.


If your medical condition is life threatening, call 911. For established patients, there is a physician on-call 24 hours a day, 7 days a week, to help with urgent medical problems. If an emergency occurs after hours, call our office number 470-308-3365 and you will receive instructions on how to contact the doctor. If your problem is not truly medically urgent, please wait and call during normal business hours. Prescription renewal requests will be handled only during office hours. Birth control pill prescriptions will not be renewed by the on-call doctor at night or on the weekends.

Calling the On-Call Doctor

The on-call doctor is available to take calls regarding emergency situations. We realize that “emergency” means something a little different to each person. We try to be understanding. However, please understand that calls that are clearly not emergencies (like prescription refill requests or questions about an insurance document or a inquiries about an upcoming appointment) will necessitate a $75 charge for the on-call doctor’s time in taking your call.

Prescription Refills

The office will be glad to accept your medication request during business hours. For the fastest service, you should contact your pharmacy first and make certain that you do not have any unclaimed prescription refills available.

To call for a renewal or a refill prescription please call our main number at 470-308-3365 and press 3.

We ask that you leave the following information:

  • Your first and last name
  • Your date of birth
  • A phone number where you can be reached
  • Your doctor who is prescribing for you
  • Any allergies that you have
  • The name and dosage of the medication that you need refilled or renewed
  • The name and phone number of your pharmacy
  • You may also send us your prescription request through the patient portal.

Please note: Prescription renewal requests will be handled only during office hours. Birth control pill prescriptions will not be renewed by the on-call doctor at night or on the weekends. Please review our policy on calling the on-call doctor explained above. Please allow at least 24 hours for your request to be processed.

Disability & FMLA Information

1. We realize that special forms are sometimes necessary to provide documentation of medical conditions. Completing forms is time-consuming and generally fall outside of the contractual relationship between you and your insurance company. We will be happy to complete these forms for you; however, there will be a fee that must be paid prior to completion and a medical release form must be signed.

2. Our policy regarding completion of all forms is as follows:

Forms and a signed authorization to release medical information may be delivered directly to the office or faxed to 770-627-5228.

Our fee to complete disability forms, FMLA, life insurance, letters and any other additional correspondence is $10 per page up to a max of $50.

The patient information portion of the form must be completed prior to processing.
Once we receive your form(s) and your signed authorization to release your medical information, please allow 5 to 7 business days for processing of the form.

All completed forms will be mailed or faxed to the disability carrier/employer as indicated by the patient or may be picked up at our office.