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312.573.3700 Fax: 312.573.3705 676 North St. Clair, Suite 1800 Chicago, IL 60611

Payment Policy

Please download the full copy of our payment policy, print, sign and bring it to your scheduled appointment. If you are not able to print it, we will provide you with a copy of this form at the time of your visit.

There is a $50 cancellation fee for appointments cancelled with less than 48 hours notice.

Download Payment Policy Here
(You will need a free Adobe Acrobat Reader to open this PDF file. You can download it here).

I hereby acknowledge the following payment policy of Progressive Care for Women (PC4W):

  1. Payment of copays, patient portions and balances due are expected at the time that services are rendered.
  2. PC4W will submit a claim for the current services to your insurance carrier. Insurance carriers are required to pay their portion of the claim within 45 days of receipt. When an insurance carrier is required to pay PC4W for a service that has been provided, you are only responsible for what is considered the patient portion of the claim. However, if your insurance carrier delays or withholds payment of its portion for more than 90 days from the date of service, both the insurance and patient portions of your account then become your responsibility. If we subsequently receive payment from your insurance carrier, we will credit your account for the amount of the payment.
  3. After your insurance carrier pays its portion of the claim, you may be responsible for a patient portion, due to such factors as uncovered services, copayments or unmet deductibles, as outlined in your particular insurance plan. Once your insurance company sends you your explanation of benefits (EOB), your credit card will be automatically processed for your remaining patient portion, and a receipt will then be emailed.

We strongly suggest that you monitor your account and the explanation of benefit forms that you receive from your insurer. You should resolve all disputes involving patient portions and explanations of benefits with your insurance carrier.