New Clients

New Client Forms

New Client Deposit Agreement Form

To use the fillable PDF form below, please download and save the form to your desktop first. After saving the form, open it directly from your computer, fill it out and save your changes. If you know how to electronically sign it, please do so. Otherwise print out the form and sign it. After completing and signing the form, please email the form or a photo of it to info@womansafehealth.com, fax to 734-477-5111 or mail to 2340 E. Stadium Blvd. Ste 8 Ann Arbor, MI 48104.

Please keep in mind that all new client intake forms are called back on a first come, first serve basis. In addition, both Herstory Form and New Client Deposit Agreement must be received in order to begin the process.

New Client Deposit Agreement

Once WomanSafeHealth has received your form and you have indicated that you prefer to use a credit card, the office staff will contact you to complete payment and set up an appointment. If you are using Paypal, or sending a check, money order, or cash with your new client deposit agreement, WomanSafeHealth will need to make sure your payment has cleared before the office staff will contact you to set up your new client appointment. If you have not heard from staff within 3 business days, please feel free to contact the office at 734-477-5100 or email us at info@womansafehealth.com.

WomanSafeHealth Herstory Form

If you have a new client appointment, please fill out as much of this form as you would like to. We will complete your health herstory together when we see you for your appointment.

To use the fillable PDF form on this page, please download and save the form to your desktop first. After saving the form, open it directly from your computer, fill it out and save your changes. Please do not fill it out from an internet tab because your changes will not save.

WomanSafeHealth Herstory Form

After your changes are saved, you may return it to our office in one of the following ways:
1) bring the completed form to your appointment as a paper copy or on a jump drive, or
2) email the completed form to info@womansafehealth.com, or
3) mail the completed form to 2340 E. Stadium Blvd Ste. 8 Ann Arbor, MI 48104, or
4) fax the completed form to 734-477-5111

Clients Under 18 Policy

WomanSafeHealth is highly committed to protecting the privacy and confidentiality of all clients* including those less than 18 years old. Medical care or counseling that involves issues of birth control, sexually transmitted infections, pregnancy or substance abuse is kept confidential between the client and WomanSafeHealth provider as required by Michigan law.** Information about the medical care provided, including diagnoses, treatment and follow up for young clients will only be shared after written authorization from the client has been received. The fee schedule for medical care and other WomanSafeHealth services is the same for all, including clients under 18, and payment is expected at the conclusion of the appointment. We encourage all clients to make their own appointments. All clients are welcome to bring parents, friends or other support individuals to their appointments if they wish.

*WomanSafeHealth serves women, girls, trans and gender nonconforming people.
**WomanSafeHealth staff are mandated reporters when there is suspicion or evidence of child or elder abuse or neglect.

 

If you have any questions, please contact our office at 734-477-5100 or info@womansafehealth.com

Pricing

WomanSafeHealth Fee Schedule

WomanSafeHealth is a fee-for-service medical practice. Payment is due in full at the time of service, except for your initial visit. A non-refundable deposit is required to make your initial appointment. We accept credit cards, debit cards, PayPal, cash, checks and money orders. We welcome clients without and with insurance. We provide a coded medical receipt at the time of your visit, which can be submitted to an insurance company, health savings account or used for tax purposes.

Although we do not accept any health insurance for payment of office visits, we ask that you bring health insurance information with you for ordering tests so that hospitals and laboratories can bill your insurance directly.

Gift certificates are available for all services and products.

For clients interested in hiring a WomanSafeHealth Woman Advocate to assist with submitting claims and insurance issues, visit our advocacy page and contact our advocates directly about your specific claims process, grievances, and navigating your insurance coverage for an OON (Out of Network) doctor.

New Client Appointment Deposit

Deposit Required First Appointment Requested
$300.00 Physician Visit
$150.00 Acupuncture & Oriental Medicine
$165.00 Holistic Psychotherapy
$60.00 Woman Advocacy
$80.00 Massage Therapy

Cancelled appointments with little or no notice often cannot be filled. To do our best to honor new clients, existing clients and WomanSafeHealth staff, we require a non-refundable deposit to reserve a new client appointment. When you keep your appointment your deposit is applied to the cost of your initial visit. Please fill out the New Client Deposit Agreement. Once your payment has been processed you will be able to set up your new client appointment.

New Client Missed Appointment Fees

Missed Appointment Fee First Appointment Requested
$300.00 Physician Visit
$150.00 Acupuncture & Oriental Medicine
$165.00 Holistic Psychotherapy
$60.00 Woman Advocacy
$80.00 Massage Therapy

The New Client Missed Appointment Fee will apply if you cancel your appointment with less than one week’s notice. If you cancel your new client appointment with more than one week’s notice, your deposit will remain on your account at WomanSafeHealth as a credit, which can be applied to another new client appointment, gift certificates, classes, groups, services or products. For example, a Monday new client appointment scheduled for 10 a.m. must be cancelled no later than 10 a.m. of the preceding Monday. Cancellations made with less than one week’s notice will forfeit the deposit without exception. The deposit will be applied to the new client missed appointment fee. If you have previously used your deposit to cover a new client missed appointment fee, another deposit will be required prior to scheduling another new client appointment.

Empowering WomanCare and Gynecology

New Client Office Visit with Elizabeth Shadigian, MD
Your first visit with Elizabeth will be a minimum of 60 minutes, but many new clients need longer. Her fees are based on time spent with each client, plus Pap smears or separate procedures.
Well-Woman “Annual” Visit with Elizabeth Shadigian, MD
$330.00 with Pap smear
$300.00 without Pap smear
Lab work is billed separately. The lab fee through WomanSafeHealth for a Pap smear read at MLABS is $39 if you do not have insurance or your insurance does not cover a Pap.
Each Well-Woman Visit lasts 60 minutes and includes 50 minutes of consultation with Elizabeth.

Office Visits, Phone Visits, and Email Correspondence for Established Clients
10 minute visit – $50.00
15 minute visit – $75.00
30 minute visit – $150.00
60 minute visit – $300.00
In addition to face to face or phone time, all time needed for writing and executing prescriptions, referrals, tests, emails and coordination of care is reflected in the medical charges.

Integrative Psychiatry

New Client Office Visit with Marnie Burkman, MD
90 min new client – $450 (Each new client visit lasts 90 minutes and includes 75 minutes of consultation with Marnie. Labs are billed separately.)

Office Visits, Skype Visits, and Email Correspondence for Established Clients
10 minute visit – $50.00
15 minute visit – $75.00
30 minute visit – $150.00
60 minute visit – $300.00
In addition to face to face or phone time, all time needed for writing and executing prescriptions, referrals, tests, emails and coordination of care is reflected in the medical charges.

Special Requests Outside of Visits
Prescription Refills (up to 1 week to process)
All prescriptions requested outside of your scheduled appointments are billed at $20.00 for 1-2 prescriptions. Some medications require an office or phone visit. These include pain medications, anxiety and depression medications, etc. Dr. Shadigian, Dr. Burkman and staff will be glad to discuss any questions you have regarding your specific medication. A client must have been seen within a year of their request for refills to be considered.

Requisitions and Letters (up to 1 week to process)
All bloodwork and radiology requisitions, brief letters and referrals outside of your scheduled appointments are billed at $20.00 per request. Some requisitions, referrals and letters require more extensive time which is billed accordingly. A client must have been seen in the office within a year for the request to be considered.

Prior Authorizations for Medications and Tests (up to 1 week to process)
Many insurance companies require extensive paperwork that a physician must fill out for your medications and tests to be covered. If you would like WomanSafeHealth to proceed with the paperwork for prior authorizations, you must approve this service ahead of time, which costs $40.00 per request. WomanSafeHealth cannot guarantee approval from your insurance company.

Medical Records (up to 1 month to process)
Simple requests, such as faxing labs and other test reports up to 20 pages may only take up to one week. However, complete medical records may take 1-2 months to process, and may involve a fee consistent with the state of Michigan laws. Summaries of care may also be requested for a fee.

Changes to Billing Documentation (up to 1 month to process)
If your insurance company requires different procedure of diagnoses codes for reimbursement, we would be happy to provide this to you without a fee.

After Hours Physician Surcharge
An after-hours fee of $150 is charged on top of the normal hourly fee for appointments starting before 8am, after 6pm, weekends and holidays.

Acupuncture & Oriental Medicine

New Client Office Visit with Kristin Whitfield, L Ac, Dipl OM, MAOM
90 min new client – $150 (Additional herbal medicine, electro-stimulation and needle fees may apply.)

Office Visit with Kristin Whitfield, L Ac, Dipl OM, MAOM
30 minute visit – $50.00
60 minute visit – $100.00
90 minute visit – $150.00

Facial Rejuvenation Packages 10 sessions, $1,100
Discounted Care Plans are available for all clients interested in a regular, weekly commitment. Please call to inquire.

Massage Therapy

Visit with Elise Aikman, BA, LMT
30 minute massage and/or Polarity visit – $40.00
60 minute massage and/or Polarity visit – $80.00
90 minute massage and/or Polarity visit – $120.00
Discounted Care Plans are available for all clients interested in a regular, weekly commitment. Please call to inquire.

Holistic Psychotherapy & Wellness Coaching

New Client Office Visit with Andrea Hill, LLSMW
90 min new client – $165.00
Office Visit with Andrea Hill, LLMSW
30 minute visit – $55.00
60 minute visit – $110.00
90 minute visit – $165.00

Missed Appointment/Late Cancel Full Fee

A Missed Appointment/Late Cancel full fees applies if you cancel your appointment less than 24 hours before your scheduled appointment. For example, a Monday 9am appointment must be cancelled by 9am Friday to avoid this fee.