HENRY FERTILITY INSURANCE VERIFICATION FORM

Please complete this insurance verification form prior to your visit with the doctor. Use this form as a questionnaire when calling the member services number on your insurance card.

**It is your responsibility to call your insurance company and/or your primary physician for referral authorization. Thereafter you are responsible to inform the office staff of referral updates, extensions and/or change of insurances.

If this form is not completed, you will be considered a self-pay patient.

Patient Name

First NameLast Name

Email

example@example.com

Today's date

Date

Insurance Company

Effective Date of Policy

Date

Insurance phone number for verification

Policy Deductible

What is your annual deductible?

Amount Met

How much of your deductible has been met this year?

Coinsurance

Do you have Coinsurance? if so, please list it here.

Is there a Specialist Office Visit Co-Pay?

YESNO

If YES, what is the amount?

Does your policy require a referral to see a Specialist?

YESNO

Do you have to go to certain labs, hospitals, pharmacies? If yes please list the names of the required facilities: **(Please note if your insurance allows you to go anywhere, indicate so in the space provided by typing the word ANYWHERE.)**

Hospital:

If you are required to go to specific hospital(s), please list them here.

Labs:

If you are required to go to specific lab(s), please list them here.

Pharmacy:

If you are required to go to specific pharmacy(s), please list them here.

**Please contact your insurance company prior to your appointment and ask the following questions**

If we are seeing you for infertility related services, does your policy cover infertility services?

YESNO

If YES, does your policy require precertification or a pre-determination letter for these services?

YESNO

Are ultrasounds and blood draws with an infertility diagnosis considered diagnostic CPT codes: 76857 (ultrasound) AND 82670 (blood test) with Diagnosis of N97.9 for example.

YESNO

Is CPT code 58340 (Hysterosalpingogram or HSG) a covered service?

YESNO

If you answered YES for the prior question, Does it require prior authorization?

YESNO

NOTES:

Please provide any additional notes here.

I understand that this form must be competed accurately, which may require that I call my insurance company PRIOR to my first visit, and that it is part of my medical record. I also understand that if I do not fill out this form to completion, claims for infertility treatment will not be sent to my insurance as Henry Fertility will assume I do not have infertility benefits on my policy.

PATIENT SIGNATURE

Date

Please verify that you are human*

Insurance Verification Form