Outside Monitoring Patient Registration Form

Outside Monitoring Patient Registration Form
Appointment Date*

MonthDayYear
Date
Appointment Day*
Time*

Hour Minutes

AM/PM Option
PATIENT INFORMATION: **FEMALE PATIENT ONLY**
Patient Name*

First NameLast Name
Middle Initial*
Maiden Name
Patient E Mail Address*
example@example.com
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Home Phone
Patient Cell Phone*
Patient Date of Birth:*

MonthDayYear
Date
Patient Age
Sex
SS#
Ethnicity
Marital Status
Are you insured?*

YES, I have insurance for this procedure.NO, services to be cash pay.

PHYSICIAN INFORMATION
Ordering Physician*
Physician Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Phone*
Referring Agency*
Referring Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referring Agency Phone
Contact at the Agency

First NameLast Name

INSURANCE INFORMATION (if applicable)
Company ID#
Group#
Insurance Company Phone
Who is your insurance through?

PatientSpouseSignificant OtherParentOther
Please list the Social Security number for the person who carries you on insurance
Please provide the Date of Birth for the person who carries you on insurance.

MonthDayYear
Date

IN CASE OF EMERGENCY CONTACT: (OTHER THAN SPOUSE)
Emergency Contact Name*

First NameLast Name
Relationship*
Emergency Contact Home Phone
Emergency Conact Work Phone
Emergency Contact Cell Phone*
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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
Initial*
Please provide your initials to authorize Consent to Treat.
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
Initial*
Please provide your initials to authorize.
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
Initial*
Please provide your initials for agreement.
I understand the above and fully understand the terms thereof:
SIGNATURE OF MOINITORED PATIENT OR RESPONSIBLE PARTY*

Clear
DATE*

MonthDayYear
Date

Financial Policy

Monitoring Patients Only
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.
Initial
Please provide your initials that you understand and agree.
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.
Initial
Please provide your initials that you understand and agree.
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.
Initial
Please provide your initials that you understand and agree.
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.
Initial
Please provide your initials that you understand and agree.
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.
Initial*
Please provide your initials that you understand and agree.
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.
Signature*

Clear
Date*

MonthDayYear
Date

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.
Signature

Clear
Date

MonthDayYear
Date

Outside Monitoring Protected Health Information Authorization

I,
(Patient name)
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Date of birth

MonthDayYear
Date
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.)
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
Do you want to include another contact?

YESNO
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
Do you want to include another contact?

YESNO
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
Do you want to include another contact?

YESNO
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
Do you want to include another contact?

YESNO
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
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.
(Patient's Signature)*

Clear
(Date)*

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

Outside Monitoring Patient Registration Form

PHYSICIAN INFORMATION

IN CASE OF EMERGENCY CONTACT: (OTHER THAN SPOUSE)

Financial Policy