PATIENT INFORMATION: **FEMALE PATIENT ONLY**
INSURANCE INFORMATION (if applicable)
Consent to Treat: I request and give consent to Henry Fertility to provide and perform such medical/surgical care, tests, procedures, drugs and other services and supplies as considered necessary or beneficial by my ordering physician/agency for my health and well being. I acknowledge that no representations, warranties or guarantees as to the results or cures have been made to me or relied upon by me. Initial
Assignment and Release: I authorize Henry Fertility to release information from my medical record to my insurance carrier(s), ordering physician and referring agency for the processing of claims for medical benefits. I request that my insurance company(s) honor my assignment of insurance benefits applicable to the services and pay all assigned insurance benefits directly to Henry Fertility on my behalf. Initial
Financial Agreement: I understand the fees for all services rendered are the full responsibility of the patient or referring agency. It is the patient's responsibility to make sure insurance payments are processed and paid promptly to Henry Fertility. In the case of default payment, 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. Initial
I understand the above and fully understand the terms thereof:
Self-Pay Monitoring Patients: If you DO NOT have insurance coverage and are a self-pay patient, or if your insurance does not cover these services you will be required to pay for services rendered on the day of your visit with the clinic. You will be required to pay for any additional fees (Initial) generated during your visit.
For the insured monitoring patient: Patients are responsible for obtaining prior authorizations or referrals from their Primary Care Physician (PCP) and/or insurance company. Please bring this authorization with you to your first visit or have your PCP office mail or fax it to us prior to your visit. If you do not have a referral on the date of service, you will be asked to sign a waiver or you (Initial) will be given the option of rescheduling your appointment.
For the insured monitoring patient: Any services not authorized by your insurance company will be denied and will become your financial responsibility. Remember that prior authorization does not guarantee benefit payment. Contact your insurance company for verification of benefits.
For the insured monitoring patient: There is a $50.00 per service, per visit co-management fee for insured patients due on each date of service. We accept payment by cash, check, Visa, MasterCard or Discover.
5. For patients undergoing fertility treatment, we require that all patient responsibility balances be paid in full prior to beginning a new cycle of treatment.
Please feel free to contact our Billing Manager to answer any questions you may have regarding financial issues. Call 317.817.1800 - opt. 2
I have read and fully understand the financial policy listed above. I understand that I will be given a copy of this policy for my records.
Contract for Outside Monitoring Patients
1. As an outside monitoring patient, I understand that Dr. Henry is not my physician and the staff at Henry Fertility is not responsible for answering questions or giving opinions on the services rendered or the treatment ordered.
2. I will be on time for my monitoring appointments and realize that there are situations in which the patients under the care of Dr. Henry and the Henry Fertility staff will come first. Although I am on time, I realize my appointment time could be subject to delay.
3. All questions relating to my care will be directed to the ordering physician and staff. The staff at Henry Fertility's job as the clinic is to facilitate the orders as sent by the ordering physician and report the results to them. If I have questions about the tests or results, I will direct my inquiry to my doctor's office.
I have read and fully understand the contract and understand the relationship with Henry Fertility.
Outside Monitoring Protected Health Information Authorization
request that the following options be followed for the disclosure of my Protected Health Information, (which would include your name, diagnosis, test results, and dates of service) as described in the Notice of Privacy Practices for Protected Health Information.
Henry Fertility may disclose information to the following persons (you must list name, phone number, and relationship for each.)
I understand that I have the right to revoke this authorization, in writing, at any time by sending a written notification to the Office Manager at Henry Fertility.