HENRY FERTILITY NEW PATIENT PACKET

Instructions for Form Completion
Welcome to Henry Fertility!

We do not accept walk-ins. We require 24 hours notice.

We are excited that you have chosen our team to assist you in pursuing your dreams of parenthood. We look forward to personally meeting you and assisting you in making your dreams a reality. Please read through the following instructions in order to complete the forms for your first visit.

Please take some time to read and fill out the following information with as much detail as possible PRIOR to your office visit. You will need to get insurance information from your insurance company during this process. Some items are required to complete before moving forward. You will need to initial, sign, and date several items.

After the completion of the forms, you will be able to review the PDF and if you wish, download and/or print the documents for your records.

Our Financial Policy will be printed and you will sign, along with a witness from our office when you visit for the first time.

Thank you again and if you have any issues, you may call our office at 317-817-1800.

Medical Questionnaire
Name*

First NameLast Name
Age*
What is your height*
Feet & Inches
What is your weight?*
Chief Complaint/Reason for visit*
Please give a short description for the reason you are visiting our office.
When was the first day of your last menstrual period?*

MonthDayYear
Date
How often do your periods come?*
Are the regular?*
Type "yes" or "no"
How much pain or cramping do you have with your periods?*

nonemildmoderatesevere
What pain medicine do you use for your cramps?
Please provide both Rx or over the counter medications
Are you using birth control now?*
Please type "YES" or "NO"
If "Yes", what? (check all that apply)

PillsCondomsTubalDepoproveraother
If "No", how long have you not been using birth control?
Do you experience excess facial hair?*
Please type "YES" or "NO"
Have you ever had Chlamydia, gonorrhea, pelvic inflammatory disease or PID?*
If "YES", Please list which one(s). If no, type "NO"
If you answered "YES" to the previous question, please answer when?
Please provide date and Year.

How many times have you been pregnant?*
Please enter a number between 0-5 (If your answer is more than one, we will be asking a series of questions starting with your most recent pregnancy and working towards your oldest pregnancy.)

5th Pregnancy - Year
What year was your fifth pregnancy?
5th Pregnancy - Was the baby born alive?
Please type "YES" or "No"
5th Pregnancy - Did the pregnancy end in Miscarriage?
Please type "YES or "NO"
5th Pregnancy - Was it a Tubal pregnancy?
Please type "YES" or "NO"
5th Pregnancy - Did it end in abortion?
Please type "YES" or "NO"
5th Pregnancy - How long did it take to conceive?
Please provide your estimate of how long it took to conceive.
5th Pregnancy - Was Fertility treatment required?
Please type "YES" or "NO"
5th Pregnancy - Is your current partner the father?
Please type "YES" or "NO"

4th Pregnancy - Year
What year was your fourth pregnancy?
4th Pregnancy - Was the baby born alive?
Please type "YES" or "No"
4th Pregnancy - Did the pregnancy end in Miscarriage?
Please type "YES or "NO"
4th Pregnancy - Was it a Tubal pregnancy?
Please type "YES" or "NO"
4th Pregnancy - Did it end in abortion?
Please type "YES" or "NO"
4th Pregnancy - How long did it take to conceive?
Please provide your estimate of how long it took to conceive.
4th Pregnancy - Was Fertility treatment required?
Please type "YES" or "NO"
4th Pregnancy - Is your current partner the father?
Please type "YES" or "NO"

3rd Pregnancy - Year
What year was your third pregnancy?
3rd Pregnancy - Was the baby born alive?
Please type "YES" or "No"
3rd Pregnancy - Did the pregnancy end in Miscarriage?
Please type "YES or "NO"
3rd Pregnancy - Was it a Tubal pregnancy?
Please type "YES" or "NO"
3rd Pregnancy - Did it end in abortion?
Please type "YES" or "NO"
3rd Pregnancy - How long did it take to conceive?
Please provide your estimate of how long it took to conceive.
3rd Pregnancy - Was Fertility treatment required?
Please type "YES" or "NO"
3rd Pregnancy - Is your current partner the father?
Please type "YES" or "NO"

2nd Pregnancy - Year
What year was your second pregnancy?
2nd Pregnancy - Was the baby born alive?
Please type "YES" or "No"
2nd Pregnancy - Did the pregnancy end in Miscarriage?
Please type "YES or "NO"
2nd Pregnancy - Was it a Tubal pregnancy?
Please type "YES" or "NO"
2nd Pregnancy - Did it end in abortion?
Please type "YES" or "NO"
2nd Pregnancy - How long did it take to conceive?
Please provide your estimate of how long it took to conceive.
2nd Pregnancy - Was Fertility treatment required?
Please type "YES" or "NO"
2nd Pregnancy - Is your current partner the father?
Please type "YES" or "NO"

1st Pregnancy - Year
What year was your first pregnancy?
1st Pregnancy - Was the baby born alive?
Please type "YES" or "No"
1st Pregnancy - Did the pregnancy end in Miscarriage?
Please type "YES or "NO"
1st Pregnancy - Was it a Tubal pregnancy?
Please type "YES" or "NO"
1st Pregnancy - Did it end in abortion?
Please type "YES" or "NO"
1st Pregnancy - How long did it take to conceive?
Please provide your estimate of how long it took to conceive.
1st Pregnancy - Was Fertility treatment required?
Please type "YES" or "NO"
1st Pregnancy - Is your current partner the father?
Please type "YES" or "NO"

List any complications that you had with any pregnancies:
When was your last pap smear?
Was it normal?
Have you had a mammogram?*
If so, when was your last one?
List the medicines you know that you are allergic to*
List your current medications (both prescription and over-the-counter):
List all surgeries that you have had (include C-sections and D&C’s)*
List any medical problems that you have
Do you smoke?*
Please answer "YES" or "NO"
If yes, how many packs per day?
How did you hear about Henry Fertility?*

Patient Registration Form
Which Henry Fertility office location will you be visiting?*

Methodist Medical Plaza North (Carmel, IN)Professional Office Building, AP&S Clinic,(Terre Haute)Lafayette Women’s ClinicAegis Women’s Clinic (Bloomington)Southern IN Physicians for Women (Bloomington)
What Day of the Week is your appointment?
Appointment Date

MonthDayYear
Date
Appointment Time:

Hour Minutes

AM/PM Option

PATIENT INFORMATION: **FEMALE PATIENT ONLY**
Name

First NameLast Name
Middle Initial:*
Please provide the patient middle initial
Maiden Name:*
E Mail Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:*
Please enter a valid phone number.
Cell Phone:*
Please enter a valid phone number.
Do you accept text messages on your cell phone?*

YESNO
Date of Birth:*

MonthDayYear
Date
Age*
SS#
Ethnicity *
Marital Status*

PHYSICIAN INFORMATION
Primary Care Physician
Address
City
State
Zip Code
Phone
Referring M.D.
Address
City
State
Zip Code
Phone
How did you learn about our medical practice?*

EMPLOYMENT INFORMATION
Employer
Business Phone
Address

Street Address

Street Address Line 2

CityState

Zip Code
Occupation
May we contact you at work?
Please answer "YES" or "NO"
If yes, what hours are best

SPOUSE OR SIGNIFICANT OTHER INFORMATION
What is your Spouse or Significant Other's gender?*

MaleFemaleOther
If other, please provide details
Name (of your spouse or significant Other)*
Date of Birth*

MonthDayYear
Spouse or Significant Other
Social Security Number
Spouse or Significant Other
Cell Phone*
Employer
Business Phone
Occupation
Spouse Business Address

Address

Street Address Line 2

CityState

Zip

INSURANCE INFORMATION
Member ID#
Group#
Phone
(Please provide the phone number of your insurance provider)
Who is the insurance provided through?

SpousePatientSignificant OtherParentOther
Please list social security number and date of birth of person who carries your on insurance if not already listed above:
Social Security #*
(Of person who carries your insurance)
Date of Birth

MonthDayYear
(Of the person who carries your insurance)

Patient Registration Form
IN CASE OF EMERGENCY CONTACT: (OTHER THAN SPOUSE)
Name*
Relationship*
Cell Phone*
Address*
CONTACT INFORMATION:

Our preferred method of contact is by email.
WHAT IS YOUR PREFERRED METHOD OF CONTACT?*

Emailhome phonecell phone
May we also contact you via text messaging?*

YESNO
Cell Phone Number to receive text messages
Consent to Treat: I request and give consent to my physician to provide and perform such medical/surgical care, tests, procedures, drugs and other services and supplies as considered necessary or beneficial by my physician for my health and well being. I acknowledge that no representations, warranties or guarantees as to the results or cures have been made to me or relied upon by me.
Initial*
Please provide your initials to authorize Consent to Treat.
Assignment and Release: I authorize my physician to release information from my medical record to my insurance carrier(s), or government agency for the processing of claims for medical benefits. I request that my insurance company(s) honor my assignment of insurance benefits applicable to the services and pay all assigned insurance benefits directly to my physician, on my behalf.
Initial*
Please provide your initials to authorize Assignment and Release.
Financial Agreement: I understand the fees for all services rendered are the full responsibility of the patient. It is the patient's responsibility to make sure insurance payments are processed and paid promptly to my physician. In the case of default payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees incurred to effect collection of this account or future outstanding accounts.
Initial*
Please provide you initials to authorize Financial Agreement.
I understand the above and fully understand the terms thereof:
I understand the above and fully understand the terms thereof: SIGNATURE OF PATIENT OR RESPONSIBLE PARTY*

Clear
DATE*

MonthDayYear
Date

Insurance Questionnaire
Please read through this waiver form, find the section that applies to you and if applicable, sign and date.

**If you have insurance and RCI is in your network, please disregard this form and fill out the Insurance Verification Form**
Which Insurance Situation Applies to you?*

SELF-PAY PATIENTS WITHOUT INSURANCE (Click Here if you do not have insurance, you are a self-pay patient)PATIENTS REQUIRING REFERRALS (Click here if your insurance company requires you to obtain a referral in order to see a specialist, your Primary Care Physician MUST authorize visits to the specialist BEFORE the visit occurs. If you were unable to obtain such referral, please sign the waiver below.)OUT OF NETWORK INSURANCE OVERAGE (Click here if your insurance does not include Reproductive Care of Indiana in their network, they may not cover services rendered. If this situation applies to you, please sign the waver below.PROOF OF INSURANCE (Click here if you have insurnace coverage and do not have your insurance card at your appointment or if you are waiting on insurance coverage to begin and do not have proof of said insurance, please sign the waiver below.I HAVE COMMERCIAL INSURANCE (Click here if you have insurance and are prepared to complete the Insurance verification form. you will need to contact your insurance company prior to your appointment to answer questions on the Insurance Verification Form)

Financial Policy

Please initial all areas marked and initial the appropriate areas. This page will be printed out for you upon your arrival and you must sign and date it along with a witness from Henry Fertility.
1. If you DO NOT have insurance coverage and are a self-pay patient, or if your insurance does not cover these services you will be required to pay $220.00 on the day of your visit with the doctor. This is an estimate of the charge for your initial visit. You will be billed for any additional fees generated during your visit.
Initial*
Please initial that you have read and agree to Item #1. above.
2. Patients are responsible for obtaining prior authorizations or referrals from their Primary care physician (PCP) and/or insurance company. Please bring this authorization with you to your first visit or have your PCP office mail or fax it to us prior to your visit. If you do not have a referral on the date of service, you will be asked to sign a waiver or you will be given the option of rescheduling your appointment
Initial*
Please Initial that you have read and agree to Item #2 above.
3. Any services not authorized by your insurance company will be denied and will become your financial responsibility. Remember that prior authorization does not guarantee benefit payment. Contact your insurance company for verification of benefits.
Initial*
Please Initial that you have read and agree to item #3 above.
4. Co-payments or deductibles and fees for non-covered services will be collected at the time of service. We accept payment by cash, check, Visa, MasterCard, or Discover.
Initial*
Please Initial that you have read and agree to item #4 above.
5. For patients undergoing fertility treatment, we require that all patient responsibility balances be paid in full prior to beginning a new cycle of treatment.
Initial*
Please Initial that you have read and agree to item #5 above.
Please feel free to contact our Billing Manager to answer any questions you may have regarding financial issues. Call 317.817.1800 – opt. 2

I have read and fully understand the financial policy listed above. I understand that I will be given a copy of this policy for my records.
Signature*

Clear
Date

MonthDayYear
Date

Signature

Clear
Protected Health Information Authorization

This form lets us know which person s we can disclose any and all medical information to and in what manner we can leave that information.
I, (please fill out the information below)
Patient Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(Date of birth)*

MonthDayYear
Date
request that the following options be followed for the disclosure of my Protected Health Information, (which would include your name, diagnosis, test results, and dates of service) as described in the Notice of Privacy Practices for Protected Health Information.

PLEASE LIST ALL THAT APPLY:

Henry Fertility may disclose information to the following persons (you must list name, phone number, and relationship).
Contact #1 Name
Contact #1 Phone Number
Please enter a valid phone number.
Contact #1 Relationship
Contact #2 Name
Contact #2 Phone Number
Please enter a valid phone number.
Contact #2 Relationship
It is okay to contact and correspond via email at this address
example@example.com
Email is our preferred method of contact. If you prefer to be contacted by phone, please check here

I PREFER TO BE CONTACTED BY PHONE.
Phone Number
Please enter a valid phone number.
By signing below, you agree that Henry Fertility may leave Protected Health Information on my answering machine/voicemail. Phone number (home, cell, work):
Patients Printed Name

First NameLast Name
(Social Security Number)
(Patient's Signature)*

Clear
(Date)*

MonthDayYear
Date
I understand that I have the right to revoke this authorization, in writing, at any time by sending written notification to the Office Manager at Reproductive Care of Indiana.

Physician’s Disclosure of Financial Interest

We are required by law to inform you which surgery centers Dr. Henry has financial interest in. Please read through this page, fill out the appropriate fields, sign and date below.
Date

MonthDayYear
Date
Patient Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Indiana law (I.C. 25-22.5-11) generally requires a physician to make certain disclosures to a patient when the physician refers the patient to a health care entity in which the physician has a financial interest. While you are a patient, I may refer you, or the named patient for whom you are legal representative, to one of the health care entities listed below in which I have a financial interest. In each case, you may choose to be referred to another health care entity.

Beltway Surgery Center

Clarian North Medical Center

Center for Reproductive Biology of Indiana
PATIENT ACKNOWLEDGEMENT
I, the above named patient, or legal representative of such patient, hereby acknowledge receipt of, on the date indicated above, a copy of the foregoing Physician's Disclosure of Financial Interest.
Signature*

Clear
Name Printed*

Please retain the following information for your records

(If you are completing this online, you may print a copy of the .pdf form on your own, or request a copy from our office.)

Henry Fertilty

Notice of Privacy Practices for Protected Health Information

Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities.

For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call your name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We will share your protected health information with third-party "business associates" that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the other services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Contact to request that these materials not be sent to you.

We may use or disclose your demographic information and the dates that you received treatment from your physician, as necessary, in order to contact you for fundraising activities supported by our office. If you do not want to receive these materials, please contact our Privacy Contact and request that these fundraising materials not be sent to you.

Uses and Disclosures of Protected Health Information Based Upon Your Written Authorization

Other uses and disclosures of your protected health information will be made only with your written authorization unless otherwise permitted or required by law as described below. You may revoke this authorization at any time, in writing, except to the extent that your physician or the physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Object

We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of your protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.

Facility Directories: Unless you object, we will use and disclose in our facility directory you name, the location at which you are receiving care, your condition (in general terms), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people that ask for you by name. Members of the clergy will be told your religious affiliation.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice, please contact our Privacy Contact at (317) 817-1800.

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment of health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information that may identify you and that relates to your past, present, or future physical or mental health/condition and related health care services.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain both before and after the change. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

1. Uses and Disclosures of Protected Health Information
- You will be asked by your physician to sign this Notice of Privacy Practices. We will make a good faith effort to obtain a written acknowledgement that you received this Notice of Privacy Practices of Protected Health Information the first time we provide services to you or as soon as reasonable practicable under the circumstances. Your protected health information may be used and disclosed by your physician, our office staff, and others outside our office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to obtain payment for your health care bills and to support the operation of the physician's practice.
- Following are examples of the types of uses and disclosures of your protected health care information that the physician's office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.
- Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your health care with a third party that may need access to your protected health information. For example, we would disclose your protected health information as necessary to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
- In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g. a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.
- Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
- Others Involved in Your Healthcare: Unless you object, we may disclose to a member of you family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals in your health care.
- Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, your physician shall try to obtain your acknowledgement of our Privacy Practices as soon as reasonably practicable after the delivery of treatment. If your physician or another physician in the practice is required by law to treat you and the physician has attempted to obtain your acknowledgement, but is unable, he or she may still use or disclose your protected health information for treatment, payment, and health care operations.
- Communication Barriers: We may use and disclose your protected health information if your physician or another physician in the practice attempts to obtain an acknowledgment of our Privacy Practices from you but is unable to do so due to sustainable communication barriers.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization, or Opportunity to Object:
- Required by Law
- Public Health
- Communicable Diseases
- Health Oversight
- Abuse and Neglect
- Legal Proceedings
- Law Enforcement
- Coroners, Funeral Directors and Organ Research
- Research
- Criminal Activity
- Food and Drug Administration
- Military Activity and National Securtiy
- Worker's Compensation
- Inmates
- Requires Uses and Disclosures
2. Your Rights

Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
- You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A "designated record set" contains medical and billing records and any other records that your physician and the practice may use for making decisions about you.
- Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in a reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Contact if you have questions about access to your medical record.
- You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose and part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
- Your physician is not required to agree to a restriction that you may request. If a physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless is it is needed to provide emergency treatment. With this in mind, please discuss and restriction you wish to request with your physician. You may request a restriction by submitting a written request to our Privacy Contact.
- You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable request. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Contact.
- You may have the right to have your physician amend your protected health information. This means you may request an amendment of protect health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide youwith a copy of any such rebuttal. Please contact our Privacy Contact if you have any questions about amending your medical record.
- You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations and valid authorizations or incidental disclosures as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, for a facility director, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14th, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations.
- You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
3. Complaints
- You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Contact of your complaint. We will not retaliate against you for filing a complaint.
- You may contact our Privacy Contact at 317-817-1800 for further information about the complaint process.
This notice was published and becomes effective on April 14th, 2003
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I have received the Practice's Notice of Privacy Practices and understand that my protected health information may be used by the Practice as described in the notice.
Name

First NameLast Name
Signature*

Clear
Date

MonthDayYear
Date

Medical Release Form
Patient authorization for copy and release of medical records to Henry Fertility

I, (fill in the information below)
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(Date of Birth)

MonthDayYear
Date
(SS #)
Hereby authorize Henry Fertility to obtain copies of my health information from:
Name of Healthcare Provider
Complete Address of Healthcare Provider
Phone Number of Healthcare Provider
Fax Number of Healthcare Provider
Please enter a valid phone number.
Portion of protected health information record requested :
Please check the portion of protected health information record requested:

Complete Medical RecordPartial Medical Records (if selected, provide details below)
If partial records were selected, please provide specific details of what requested records should be included:
Please forward medical records to:

Michael A. Henry, MD

Henry Fertility

201 Pennsylvania Parkway, Suite 325

Carmel, IN 46280

317-817-1800

317-817-1810 Fax
Patient Signature*

Clear
Date

MonthDayYear
Date

Completion of New Patient Packet

Please click the Preview PDF button below to review the forms and use the BACK button if you need to go back and make changes or edits. If you are satisfied that the forms are complete, please click the SUBMIT button.
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Instructions for Form Completion

Medical Questionnaire

Patient Registration Form

PHYSICIAN INFORMATION

EMPLOYMENT INFORMATION

SPOUSE OR SIGNIFICANT OTHER INFORMATION

INSURANCE INFORMATION

Patient Registration Form

IN CASE OF EMERGENCY CONTACT: (OTHER THAN SPOUSE)

Insurance Questionnaire

SELF-PAY PATIENTS WITHOUT INSURANCE

PATIENTS REQUIRING REFERRALS

OUT OF NETWORK INSURANCE COVERAGE

PROOF OF INSURANCE

Insurance Verification Form

Financial Policy

Protected Health Information Authorization

Physician’s Disclosure of Financial Interest

PATIENT ACKNOWLEDGEMENT

Medical Release Form

Completion of New Patient Packet