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.

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.)**

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

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.