OUTSIDE MONITORING PHYSICIAN ORDER FORM

OUTSIDE MONITORING PHYSICIAN ORDER FORM
Date of Service for Monitoring:

MonthDayYear
Date
Name

First NameLast Name
Middle Initial
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.

INTAKE FORM FOR OUTSIDE CLINIC SERVICES
Monitoring Patient Information
Legal Name of patient/donor
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home phone
Work Phone
Cell Phone
Email Address
example@example.com
Date of Birth

MonthDayYear
Date

Insurance Information (if applicable)

Patient is self-pay (see credit card info below)
Insurance Carrier
ID#
Group#
Insurance Phone
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Agency Information
Name of Agency
Agency Phone
Agency Fax
Please enter a valid phone number.
Agency Address
Contact Name

First NameLast Name
Contact Email
example@example.com
Ordering Physician

Billing Information
Name of Responsible Party:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Note about billing:

We must have payment information on file prior to any services rendered. Please call or text our office directly at 317-817-1800 to provide credit card details. (The provided credit card will be automatically charged as services are rendered and an itemized receipt will be mailed or emailed to the address provided.)
INTAKE FORM FOR OUTSIDE CLINIC SERVICES

Instructions:
- Please instruct the patient to go to our website at www.henryfertility.com and follow the link on the home page to the forms page. They will need to print out the forms from the link labeled "Outside Monitoring Patients".
- Instruct patient to read through and complete all forms on the link and bring to the first appointment completed.
- Instruct patient to bring a copy of the order to each appointment.
- All ultrasounds and lab work for outside monitoring patients are rendered at 8:30am Monday - Saturday by appointment only.
Services provided in house:
- CPT 76830 baseline ultrasound
- CPT 76857 follicle ultrasound
- CPT 76817 viability ultrasound (rendered by MD to 10 weeks gestation only)
- CPT 82670 Estradiol blood test (includes Venipuncture fee)
Labs sent to LabCorp for processing: (may require additional venipuncture fee)
- FSH 83001
- LH 83002
- TSH 83003
- AMH 82397
A price sheet is available upon request. Please email request for pricing to AMarvel@henryfertility.com.

*Please provide LabCorp account for billing if applicable. If not applicable, fees per draw are due on the day of service.
LabCorp Billing Account #
**If insurance is to be utilized for services rendered, there is a $50.00 monitoring program fee per service, per day, due on the day services are rendered. For the labs to be sent to Lab Corp for processing in the case of insurance coverage, Lab Corp will bill patient or agency directly after sending their claims to insurance.
Please verify that you are human*
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OUTSIDE MONITORING PHYSICIAN ORDER FORM

INTAKE FORM FOR OUTSIDE CLINIC SERVICES

Monitoring Patient Information

Agency Information

Billing Information

Note about billing: