CRBI Patient Registration

Patient Registration Form

Center for Reproductive Biology of Indiana
Have you already booked your appointment with us? (CRBI sees patients by appointment only. We do not accept walk in patients)*

YES, I have a confirmed Date and time booked with CRBI.No, I have not booked an appointment yet.
YOU NEED TO BOOK YOUR APPOINTMENT WITH CRBI:

Prior to completing the Patient Registration form, you must first book your appointment by filling out the APPOINTMENT REQUEST FORM.

Once you have your appointment date and time confirmed, you can return here to fill out the Patient Registration Form.
Confirmed Appointment Date*

MonthDayYear
Please enter the date ONLY IF YOU HAVE ALREADY BOOKED THE APPOINTMENT WITH CRBI.
Confirmed Appointment Day*
Please type the day of the week for your appointment ONLY IF YOU HAVE ALREADY BOOKED THE APPOINTMENT WITH CRBI.
Confirmed Appointment Time*
Please provide your appointment time ONLY IF YOU HAVE ALREADY BOOKED THE APPOINTMENT WITH CRBI.

Patient Name*

First NameLast Name
Middle Initial
Maiden Name
If you have a maiden name, please provide it.
E Mail Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Cell Phone
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Age*
Sex*
Please provide your sex
SS#*
Marital Status*

Referring M.D.*
Please provide the doctor who referred you to CRBI
Practice/Clinic
Address*

Address

Street Address Line 2

CityState

Zip Code
Phone*
Fax
Please enter a valid FAX number.

SPOUSE OR SIGNIFICANT OTHER INFORMATION
Name (Spouse)
Please provide your Spouse or Significant Other's name.
Date of Birth (Spouse)

MonthDayYear
Date
Social Security Number (Spouse)
Please provide your spouse of significant other's SS #
Cell Phone (Spouse)
Please provide your spouse or significant other's cell phone number.

IN CASE OF EMERGENCY CONTACT: (OTHER THAN SPOUSE)
Name*
Please provide a contact in case of emergency (other than your spouse or significant other).
Relationship*
Home Phone Number
Please enter a valid phone number.
Work Phone
Cell Phone

FINANCIAL POLICY
Assignment of Benefits:

I hereby authorize payment to the Center for Reproductive Biology of Indiana, LLC (CRBI) of any medical benefits payable to me. I also understand that if my insurance plan requires referral authorization or precertification, it is my responsibility to obtain these prior to my lab procedure(s I will be responsible for any and all fees for services rendered.
Initials*
I understand CRBI recommends contacting my insurance company to verify my benefits, but that I may request CRBI to submit a claim to my insurance company at any time. I understand that CRBI does not contract with insurance companies, and that all insurance billing will be applied as out-of-network benefits. Any services not authorized or charges not paid by my insurance company will become my financial responsibility. I understand that any unpaid balances will be my responsibility.
Initials*
I understand that CRBI will ask to collect lab fees prior to or at the time of service. CRBI accepts cash, check, credit card, and health savings accounts. I further understand that it is CRBI's policy to have any previous balances paid in full prior to beginning a new treatment cycle.
Initials*
Records Release:

I hereby authorize CRBI to release my records to my insurance company and primary care physician for the purpose of processing my insurance claims. This authorization shall remain in effect as long as charges are being submitted for insurance claim processing or as long as dictated by payer.
Initials*
Financial Agreement:

I understand the fees for all services rendered are the full responsibility of the patient. It is my responsibility to make sure insurance payments are paid promptly to the laboratory. In the case of default payments, 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.

I have read and fully understand the financial policy listed above. I understand that a copy of this policy can be provided to me at any time for my records.
Signature of Patient or Responsible Party*

Clear
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

IN CASE OF EMERGENCY CONTACT: (OTHER THAN SPOUSE)

FINANCIAL POLICY