David B. Schwartz M.D.

PAPSURE® AND HPV TESTING PERMISSIONS

Dear Patient,

In order to provide you with the best testing solutions, which will enable earlier detection of abnormalities or cancer, I am proud to make the following testing options available to you:

PapSure: This is a new test that combines the Pap smear with the ability to illuminate and view the cervix thoroughly. The advantage of a PapSure procedure is that it significantly improves the ability to identify abnormalities from 41% (Pap smear only) to 92% (Pap smear with PapSure). PapSure is not covered by insurance companies, and, if you decide to have the visual examination as part of your routine checkup, you responsible for the $45 fee.

HPV Testing: Human papilloma virus is the most important risk factor for determining if you are at risk for developing cervical cancer. This testing is generally covered by most insurance companies. However, some healthcare plans may require you to pay a portion of the approximately $105 charge.

Please indicate by signing and dating below, whether you want to have the PapSure® examination and/or the HPV test.

Sincerely yours,
David B. Schwartz, M.D.

	I authorize Dr. David B. Schwartz, M.D. to do the PapSure® examination together with my routine Pap smear and accept the financial responsibility of $45.

	I authorize Dr. David B. Schwartz, M.D. to perform HPV testing along with my routine Pap smear. I agree to pay any portion of the $105 fee that is not covered by my insurance.

	I do not wish to have the PapSure or the HPV test at this time.


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