Patient Registration Form
Center for Reproductive Biology of Indiana
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.
SPOUSE OR SIGNIFICANT OTHER INFORMATION
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.
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.
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.
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.
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.