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*

MonthDayYear
Date
Name of Client (exactly as name appears on insurance card)*

First NameLast NameSuffix
Name of Client's legal guardian/representative (if applicable)

First NameLast Namerelationship to client
Current Address on file with insurance company*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client's Date of Birth*

MonthDayYear
DOB
Is client a dependent child?*

NoYes
Marital Status*

MarriedSingleOther
Client's Phone for insurance verification purposes*

Area CodePhone 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. Please note that One-time Injections (i.e. Trigger Shots) ARE NOT billed directly to insurance AND those requesting these services should not use this form.)
Type of Service Requested (choose 1 or more options)*

IVF Full Stimulation CycleEgg Freezing Full Stimulation CyclePre-Frozen Embryo Transfer InjectionsPregnancy Maintenance Injections (Progesterone only)Pregnancy Maintenance Injections/Post-FET (Progesterone and other meds)Lupron injectionsNon-fertility InjectionsOther
Name and Location of Fertility Clinic*
Estimated Start of Care Date*

MonthDayYear
Date
Estimated End of Care Date*

MonthDayYear
(your projected end of service date or "trigger date")
Injection time frame requested (we only book in 2-hour time frames and not all time requests can be accommodated)*

:HourMinutesAM/PM Option
Until
until :HourMinutesAM/PM Option

Health Insurance Plan Type
Primary Insurance Information
Name of the Insured or Policy Holder (if covered person is other than client))*

First NameLast NameSuffix
Employer of Insured*
Insured Date of Birth*

MonthDayYear
Date
Name of Health Insurance Company*
Individual, Family or Employer Plan?*

IndividualFamilyEmployerOther
Type of Health Insurance Plan*

PPOHMOEPOPOSOther
Insurance ID Number*

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

Browse Files

Cancelof
Picture of BACK of insurance card*

Browse Files

Cancelof

Secondary Insurance Information

(if not applicable, then skip to next section)
Name of the Insured or Policy Holder (if covered person is other than client)

First NameLast NameSuffix
Secondary - Insured Date of Birth (if covered person is other than client)

MonthDayYear
Date
Employer of Insured
Name of Health Insurance Company
Individual, Family or Employer Plan?

IndividualFamilyEmployerOther
Type of Health Insurance Plan

PPOHMOEPOPOSOther
Insurance ID Number

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

Browse Files

Cancelof
Picture of BACK of insurance card

Browse Files

Cancelof

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
Company requesting insurance benefits check*
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*

MonthDayYear
Date
Should be Empty:

HEALTH INSURANCE & PAYMENT AGREEMENT FORM