Patient Portal
SELECT YOUR STATE BELOW
Please select your state below to view portal access and downloadable forms.
Pennsylvania Patients
To access your patient portal for Pennsylvania, please click on the link below. If you are uncertain as to whether or not you have access to a patient portal, please contact your provider’s office.
Patient Forms
• New Patient Forms
Completing and submitting the following forms before your first OB/GYN appointment will save you time upon arrival at your care center. When ready to submit, click the blue button below to upload your documents and submit to your care center.
- Patient Information/Registration & Telehealth Consent Form | en Español
- Medical History Form | en Español
- HIPAA Form | en Español
- Financial Form | en Español
Electronic Submission of Documentation
• Medical Release
- Authorization to Release Protected Health Information | en Español
- Patient Request for Access to Health Record | en Español
• Medical Release (for Patients of Main Line OB/GYN or Chester County OB/GYN Only)
We have partnered with MediCopy to fulfill your Release of Information requests. MediCopy is fully HIPAA compliant and adheres to all state and federal regulations concerning release of medical information.
Patients can request copies of their medical records at no cost, but delivery fees apply for postage! Please provide an email address on the authorization to expedite the process and delivery method. Records sent via email or to another provider are complimentary. Requests are completed within two (2) business days after receipt by MediCopy.
To request your medical records please fill out one of the following authorization forms:
- Authorization for the Release of Medical Records (Online)
- Authorization for the Release of Medical Records (Paper)
- Learn more about MediCopy’s Release of Information service
If you have any questions, please contact MediCopy:
Online Chat: MediCopy.net | Phone: 866-587-6274 | Email: [email protected]
• Returning Patient Forms
To ensure we have the most accurate and current information, we ask our returning patients to complete the following form once per year.
- Returning Patient -Record Update Form | en Español
- HIPAA Form | en Español
- Financial Form | en Español
• Mammography Release Forms
- Center for Breast Health of Langhorne
- Center for Breast Health of Paoli
- Center for Breast Health of Limerick
- Center for Breast Health of Haverford
OB/GYN of Indiana Patients
To access your patient portal for OB/GYN of Indiana, please click on the link below. If you are uncertain as to whether or not you have access to a patient portal, please contact your provider’s office.
Patient Forms
Medical Release
- Authorization to Release Protected Health Information | en Español
- Patient Request for Access to Health Record | en Español
Mammography Imaging Release Forms
New Jersey Patients
To access your patient portal for New Jersey please click on the link below. If you are uncertain as to whether or not you have access to a patient portal, please contact your provider’s office.
New Jersey Patient Forms
New Patient Forms
Completing the following forms before your first OB/GYN appointment will save you time upon arrival at your care center. When ready to submit, click the blue button below to upload your documents and submit to your care center.
- Patient Information/Registration & Telehealth Consent Form | en Español
- Medical History Form | en Español
- HIPAA Form | en Español
- Financial Form | en Español
Electronic Submission of Documentation
• Medical Release
- Authorization to Release Protected Health Information | en Español
- Patient Request for Access to Health Record | en Español
• Medical Release (for Patients of Brunswick Hills OB/GYN, Garden State OB/GYN, and Cherry Hill OB/GYN Only
We have partnered with MediCopy to fulfill your Release of Information requests. MediCopy is fully HIPAA compliant and adheres to all state and federal regulations concerning release of medical information.
Patients can request copies of their medical records at no cost, but delivery fees apply for postage! Please provide an email address on the authorization to expedite the process and delivery method. Records sent via email or to another provider are complimentary. Requests are completed within two (2) business days after receipt by MediCopy.
To request your medical records please fill out one of the following authorization forms:
- Authorization for the Release of Medical Records (Online)
- Authorization for the Release of Medical Records (Paper)
- Learn more about MediCopy’s Release of Information service
If you have any questions, please contact MediCopy:
Online Chat: MediCopy.net | Phone: 866-587-6274 | Email: [email protected]
• Returning Patient Forms
To ensure we have the most accurate and current information, we ask our returning patients to complete the following form once per year.
- Returning Patient -Record Update Form | en Español
- HIPAA Form | en Español
- Financial Form | en Español
• Mammography Release Forms
Southside OB/GYN Patients
We are currently transitioning to a new Axia Women’s Health patient portal. To create your new portal account, please call your care center and we will email you a personal link to get started. For the Indianapolis location call (317) 865-3600 and for Mooresville call (317) 584-3454
You can continue to log on to your old patient portal to access previous information, however all new appointments and medical information will be found in your new Axia patient portal so be sure to call your care center to create your new account.
Southside OB/GYN Patient Forms
If you have an upcoming appointment, you will be receiving an email seven days prior to your appointment with online forms to complete. If you did not receive this email, please print and complete the forms below prior to your appointment to save time at your care center.
All new and returning patients will need to fill these out once after April 1, 2021.
- Patient Information/Registration & Telehealth Consent Form | en Español
- HIPAA Form | en Español
- Financial Form | en Español
- Office Procedure Consent Form
Medical Release
We have partnered with MediCopy to fulfill your Release of Information requests. MediCopy is fully HIPAA compliant and adheres to all state and federal regulations concerning release of medical information.
Patients can request copies of their medical records at no cost, but delivery fees apply for postage! Please provide an email address on the authorization to expedite the process and delivery method. Records sent via email or to another provider are complimentary. Requests are completed within two (2) business days after receipt by MediCopy.
To request your medical records please fill out one of the following authorization forms:
- Authorization for the Release of Medical Records (Online)
- Authorization for the Release of Medical Records (Paper)
- Learn more about MediCopy’s Release of Information service
Disability/FMLA Forms
Forms are $30 for the first form and $15 for each additional form turned in at the same time. After payment is received, Disability/FMLA forms are completed and sent to the requestor within three business days.
Turn in your form(s) to be completed via the following options:
- Email: A PDF of the form can be sent to [email protected]
- Fax: 888.972.2476
- Mail: MediCopy Attn: Form Completion Dept. 8 City Blvd. Suite 400, Nashville, TN 37209
- In-Person: Drop the blank Disability or FMLA form off at your doctor’s office.
Please include an intake form with your paperwork.
- Authorization for the Release of Disability/FMLA form (Online)
- Authorization for the Release of DIsability/FMLA form (Paper)
Learn more about MediCopy’s Form Completion service
If you have any questions, please contact MediCopy:
Online Chat: MediCopy.net | Phone: 866-587-6274 | Email: [email protected]
Indiana Urogynecology Patients
We are currently transitioning to a new Axia Women’s Health patient portal. To create your new portal account, please call your care center at (317) 790-3355 and we will email you a personal link to get started.
You can continue to log on to your old patient portal to access previous information, however all new appointments and medical information will be found in your new Axia patient portal so be sure to call your care center to create your new account.
Indiana Urogynecology Patient Forms
If you have an upcoming appointment, you will be receiving an email seven days prior to your appointment with online forms to complete. If you did not receive this email, please print and complete the forms below prior to your appointment to save time at your care center.
All new and returning patients will need to fill these out once after April 1, 2021.
- Patient Information/Registration & Telehealth Consent Form | en Español
- HIPAA Form | en Español
- Financial Form | en Español
- Office Procedure Consent Form
Medical Release
We have partnered with MediCopy to fulfill your Release of Information requests. MediCopy is fully HIPAA compliant and adheres to all state and federal regulations concerning release of medical information.
Patients can request copies of their medical records at no cost, but delivery fees apply for postage! Please provide an email address on the authorization to expedite the process and delivery method. Records sent via email or to another provider are complimentary. Requests are completed within two (2) business days after receipt by MediCopy.
To request your medical records please fill out one of the following authorization forms:
- Authorization for the Release of Medical Records (Online)
- Authorization for the Release of Medical Records (Paper)
- Learn more about MediCopy’s Release of Information service
Disability/FMLA Forms
Forms are $30 for the first form and $15 for each additional form turned in at the same time. After payment is received, Disability/FMLA forms are completed and sent to the requestor within three business days.
Turn in your form(s) to be completed via the following options:
- Email: A PDF of the form can be sent to [email protected]
- Fax: 888.972.2476
- Mail: MediCopy Attn: Form Completion Dept. 8 City Blvd. Suite 400, Nashville, TN 37209
- In-Person: Drop the blank Disability or FMLA form off at your doctor’s office.
Please include an intake form with your paperwork.
- Authorization for the Release of Disability/FMLA form (Online)
- Authorization for the Release of DIsability/FMLA form (Paper)
Learn more about MediCopy’s Form Completion service
If you have any questions, please contact MediCopy:
Online Chat: MediCopy.net | Phone: 866-587-6274 | Email: [email protected]