Client Health Insurance and Payment Agreement Form

HEALTH INSURANCE & PAYMENT AGREEMENT FORM

(you will need a front and back copy of your insurance card)
Form completion date *

Month Day Year
Date
Name of Client (exactly as name appears on insurance card) *

First Name Last Name Suffix
Name of Client's legal guardian/representative (if applicable)

First Name Last Name relationship to client
Current Address on file with insurance company *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Client's Date of Birth *

Month Day Year
DOB
Is client a dependent child? *

No Yes
Marital Status *

Married Single
Client's Phone for insurance verification purposes *

Area Code Phone Number
Client's Email for insurance verification purposes *
example@example.com
SERVICES REQUESTED

(Submit your insurance requests at least 4 weeks before your estimate start of care date for priority consideration.)
Type of Service Requested (choose 1 or more options) *

IVF Full Stimulation Cycle Egg Freezing Full Stimulation Cycle Pre-Frozen Embryo Transfer Injections Trigger Shot only Pregnancy Maintenance Injections (Progesterone only) Pregnancy Maintenance Injections (Progesterone and other meds) Lupron injections Non-fertility Injections
Estimated Start of Care Date *

Month Day Year
Date
Estimated End of Care Date *

Month Day Year
(your projected end of service date or "trigger date"
Health Insurance Plan Type
Primary Insurance Information
Name of the Insured or Policy Holder (if covered person is other than client)) *

First Name Last Name Suffix
Employer of Insured *
Insured Date of Birth *

Month Day Year
Date
Name of Health Insurance Company *
Individual, Family or Employer Plan? *

Individual Family Employer
Type of Health Insurance Plan *

PPO HMO EPO POS
Insurance ID Number *

Prefix (if applicable) Identification/Policy # Suffix (if applicable)
Insurance Group Number *
Picture of FRONT of insurance card *

Browse Files

Cancel of
Picture of BACK of insurance card *

Browse Files

Cancel of
Secondary Insurance Information

(if applicable)
Name of the Insured or Policy Holder (if covered person is other than client)

First Name Last Name Suffix
Secondary - Insured Date of Birth (if covered person is other than client)

Month Day Year
Date
Employer of Insured
Name of Health Insurance Company
Individual, Family or Employer Plan?

Individual Family Employer
Type of Health Insurance Plan

PPO HMO EPO POS
Insurance ID Number

Prefix (if applicable) Identification/Policy # Suffix (if applicable)
Insurance Group Number
Picture of FRONT of insurance card

Browse Files

Cancel of
Picture of BACK of insurance card

Browse Files

Cancel of
Additional Information

(Please include any additional information that you feel will help CNS staff in verifying your insurance benefits.)
Pertinent, additional information (optional)
Terms and Conditions
I authorize the release of any medical or other information necessary to process an insurance claim. I understand that CNS will diligently attempt to get accurate information regarding my health insurance benefits. I will not hold CNS liable for insurance nonpayment due to misquoted benefits. I acknowledge that I am responsible to know and understand my benefits plan. If CNS accepts me as a client, then CNS will file my insurance claims if in-network for me as a courtesy. I am ultimately responsible for any co-pay(s) and all charges my insurance company does not pay, except for contracted network provider discounts that may apply. I also request assigned benefits be paid to CNS.
Signature of client or client's legal guardian/representative *

Clear
Date of signature *

Month Day Year
Date
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

HEALTH INSURANCE & PAYMENT AGREEMENT FORM

SERVICES REQUESTED

Health Insurance Plan Type

Primary Insurance Information

Secondary Insurance Information

Additional Information

Terms and Conditions