We’re so excited to take care of you at Capital Women’s Care Ashburn.
If you’re a new patient at our Ob-Gyn Clinic, or this is your first visit to a gynecologist, we’ve written some tips to assure you that everything will be quick, easy, and painless!

Capital Women's Care: Ashburn - OBGYN

1 Before You Visit

Instead of arriving 15 minutes prior to your appointment to fill out paperwork in our office, you can fill out all paperwork in the comfort of your own home here [link]. If you do not want to fill out the paperwork ahead of time, please arrive 15 minutes prior to your appointment to ensure you have enough time.

You may also want to write down a list of questions you have for the doctor so that you don’t forget – no question is too strange! We’re here to help! And don’t forget to bring your ID and insurance card!

Capital Women's Care: Ashburn - OBGYN

2 Your First Visit

When you arrive, tell the nurse that this is your first visit to the gynecologist. Your appointment will initially be similar to a regular check-up, but will include an examination of your genital area.

Your provider may also check your breasts to quickly ensure that there are no lumps or bumps. If your parent is with you at the appointment, you can have them come into the exam room with you (but only if you want them to).

If you are sexually active, your doctor may recommend that you get tested for STDs. Make sure to be honest with your doctor about your sexual habits so he can give proper recommendations, the doctor won’t share any information with your parents unless you give him permission!

Depending on your doctor and if you are reporting specific symptoms, your provider may insert a small device called a speculum into your vagina to ensure everything looks healthy inside. Don’t worry, it’s smaller than a tampon. Your provider may also insert a gloved finger into your vagina while pushing on your abdomen to examine your uterus and ovaries.

Capital Women's Care: Ashburn - OBGYN

3 After Your Visit

Your provider will follow up after your appointment if you are awaiting any test results, blood work results, or anything else they may have been checking up on. If you took an STD test, your provider likely will not contact you unless you tested positive for anything. When your provider contacts you, he may give you a plan for treatment and follow-up, you can also feel free to ask any additional questions.

Forms & Policies

Appointment Policies

Capital Women’s Care welcomes new and returning patients. Our staff is committed to ensuring that the administrative aspects of your visit are handled with the same high level of professionalism and care as medical portion.

  • Please arrive promptly and allow 20 minutes to update/complete the required paperwork.
  • You must bring your insurance card and driver’s license (or other legal picture id).
  • New patients will need to complete medical history, registration, and HIPAA forms; all patients will need to complete the registration form.

Emergencies: Obstetrics and Gynecology  often involves emergency procedures, surgical delays, and deliveries. We ask for your understanding, and if we are running behind schedule, our staff may attempt to notify you.

Cancellations: We also request that you arrive promptly for your visit. If you are unable to keep your appointment or are going to be late, please call the office as soon as possible. Cancellations without 24 hours notice or missed appointments may be subject to fees.

You can print the following forms out as needed, complete them at home, and bring them with you to save some time on the day of your appointment. (HIPAA Use & Disclosure for first time patients only) )

Permission to Treat without Parent or Legal Guardian Present

Capital Women’s Care must receive permission from a child’s parent or legal guardian before providing treatments for an injury or illness that is non-life threatening. This form gives us legal permission to treat your child in case you cannot accompany them to the practice for treatment.


  • A parent/legal guardian must attend a minor’s first visit at Capital Women’s Care.
  • A “Permission to Treat a Minor without a Parent/Guardian Present” form is required for a minor to be seen without his/her parent/legal guardian.
  • In certain circumstances, in accordance with State and Federal laws, parent/guardian permission may not be needed for adolescents being seen for concerns of “heightened sensitivity” such as STD testing, family planning, mental health, et cetera.

Permission to Treat without Parent or Legal Guardian Present


You can print the following forms out as needed, complete them at home, and bring them with you to save some time on the day of your appointment. (HIPAA Use & Disclosure for first time patients only). The documents are fillable PDF files. If you wish to fill it out electronically you will need to open the document, save it to your computer, then complete the document and print to bring it with you the day of your appointment.


Patient Information Form

Use and Disclosure of Protected Health Information (HIPAA form)

GYN intake form

Review of Systems (ROS)

Well Woman Exams:

Patient Information Form

Use and Disclosure of Protected Health Information (HIPAA form)

Hereditary Cancer Questionnaire

Well Woman Visit Disclaimer for Additional Charges

Review of Systems (ROS)

Pregnancy Confirmation/New OB:

Patient Information Form

Use and Disclosure of Protected Health Information (HIPAA form)

OB intake form

Review of Systems (ROS)

Ultrasound Consent

Medications Safe for Use During Pregnancy/Breastfeeding

Medical Record Release Policies

Federal and State law requires the patient’s signature, or that of an authorized personal representative, to release or transfer medical records. The patient records are defined as all records that relate to the health of the patient and are prepared by or under supervision of a health care provider associated with Capital Women’s Care. We maintain the patient’s rights that all medical records are kept confidential according to all federal and state laws.

Please note that in some cases, a fee will be charged for medical record copies. The medical record department will be happy to provide you information about fees, expected turnaround times and other information related to your request.

Patients that provide records from another physician, outside of CWC, are encouraged to retain their own copy as Capital Women’s Care cannot provide a copy.

Please click below to print the applicable form:

Records Release TO Capital Women’s Care


Records Release FROM Capital Women’s Care


Prescription Refills Policy

  • Prescription refills will be processed only for established patients who have been seen within the past 12 months.
  • Your physician will review your chart and the refill will be called in directly to your pharmacy, within 24 hours of receipt, on the next business day. If your physician feels an office visit is necessary before a refill can be given, you will be notified by phone.
  • One additional month of refill birth control pills can be called in for established patients. This will allow time to schedule an annual visit.

Billing Information

Our billing company is NextGen Revenue Cycle Management and they can be reached at 800-529-3489.

Privacy Practices

Understanding Your Health and Record Information

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is created. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a basis for planning care and treatment and serves as a means of communication among the many health professionals who contribute to your care. Understanding what is in your record and how your health information is used helps you to ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.

Your Health Information Rights

Unless otherwise required by law, your health record is the physical property of the healthcare practitioner or facility that compiled it; the information belongs to you. You have the right to request a restriction on certain uses and disclosures of your information, and request amendments to your health record. This includes the right to obtain a paper copy of the notice of information practices upon request, inspect, and obtain a copy of your health record. You may obtain an accounting of disclosures of your health information, request communications of your health information by alternative means or at alternative locations, revoke your authorization to use or disclose health information except to the extent that action has already been taken.

Our Responsibilities

This organization is required to maintain the privacy of your health information, and in addition, provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you. This organization must abide by the terms of this notice, notify you if we are unable to agree to a requested restriction, accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you have provided. If we maintain a website that provides information about our customer services or benefits we will post our new notice on that Web site. We will not use or disclose your health information without your authorization, except as described in this notice.

Examples of Disclosures for Treatment, Payment, and Health Operations

We will use your health information for treatment. For example: Information obtained by a healthcare practitioner will be detailed in your record and used to determine the course of treatment that should work best for you. By way of example, your physician will document in your record their expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations (example varies by practitioner type). We will also provide your other practitioners with copies of various reports that should assist them in treating you. We will use your health information for payment. For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. We will use your health information for regular health operations. For example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

  • Business Associates: There may be some services provided in our organization through contracts with Business Associates. Examples include physician services in the emergency department and radiology, certain laboratory tests, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose some or all of your health information to our Business Associate so that they can perform the job we have asked them to do. To protect your health information, we require the Business Associate to appropriately safeguard your information.
  • Directory (inpatient settings): Unless you notify us that you object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name.
  • Notification: We may use or disclose information to notify, or assist in notifying, a family member, personal representative, or another person responsible for your care, your location, and general condition.
  • Communication with family: Health professionals, using their best judgment, may disclose to a family member, other relatives, close personal friends or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.
  • Research (inpatient): We may disclose information to researchers, when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information, has approved their research.
  • Funeral directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties.
  • Organ procurement organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged

Notice of Privacy Practices (First time patients only, unless requested)

Notice of Privacy Practices