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I understand that as part of my health care, Advanced Fertility Group oritinates and maintains paper and / or electronic records describing my health history, symptoms, examinations, and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as: A basis for planning my care and treatment, a means of communication among the many health professionals who contribute to my care, a source of information for applying my diagnosis and surgical information to my bill, a means by which a third party payer can verify that services billed were actually provided and a tool for routine health care operations such as assessing quality and reviewing the competency of health care professionals.
I understand and have been provided with a NOTICE OF PRIVACY PRACTICES that provides a more complete description of the information uses and disclosures. I understand that I have the following rights and privileges: The right to review the notice prior to signing the consent, the right to object to the use of my health information for directory purposes, and the right to request restrictions as to how my health information may be disclosed to carry out treatment, payment, or health care operations.
I understand the Advanced Fertility Group is NOT required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand by refusing to sign the consent or revoking this consent, Advanced Fertility Group may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.
I further understand that Advanced Fertility Group reserves the right to change their notice and practices prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should we change our notice, we will send a copy of any revised notice to the address I’ve provided via United States Mail.
I understand that as part of this organization’s treatment, payment, or health care operation, it may become necessary to disclose my protected health information to another entity, such as a referred health service or M.D. on your behalf, and I CONSENT to such a disclosure for these permitted uses, including via fax.
I understand and have been provided with a NOTICE OF PATIENT CONCERNS POLICY AND PROCEDURES that provides information regarding patient concerns related to Advanced Fertility Group.
In addition to my insurance provider THE FOLLOWING PERSON OR PERSONS may have access to my health information besides indicated providers as previously mentioned. I full understand and accept the terms of this consent.
We are committed to providing you with the best possible care and we are pleased to discuss our professional fees with you at any time. The following information is provided to ensure that each patient understands their financial responsibility prior to seeking treatment at Advanced Fertility Group.
1. All patients must schedule a financial consult once they have received a treatment plan and prior to starting treatment.
2. Patients are responsible for obtaining prior authorizations from their Primary Care Physicians (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 first visit. We will preauthorize with your insurance carrier all surgical and hospital treatments. (initial)
3. After the initial consultation, it is your responsibility to confirm that your PCP or insurance company has provided us with authorization prior to any treatment. Any services not authorized by your insurance company will be denied and ultimately will become your financial responsibility. Remember that prior authorization does not guarantee benefit payment. Contact your insurance company for verification of benefits.
4. We request payment in full be made for the following treatments:
a. Artificial Insemination
b. Donor Sperm
C. Tubal Reversals
5. For patients undergoing IVF or GIFT, a down payment is required for both the physician’s office and hospital charges. Remaining balances due at predetermined times. This will be discussed in detail during your financial consultations.
6. No one is as interested in your insurance coverage as you are. For this reason you have more influence with your insurance company than we do and we count on your participation when there is a problem with payment for services you received. WE ENCOURAGE YOU TO TAKE AN ACTIVE ROLE IN UNDERSTANDING YOUR INSURANCE BENEFITS AND COVERAGE PRIOR TO BEGINNING ANY FERTILITY THERAPY.
7. Insurance authorizations for treatment can take up to 6 weeks to obtain from insurance companies and can be procedure specific or cycle specific. When a treatment plan has been determined, and authorization received, you will be notified by our office. If you choose to start a treatment before insurance authorization has been received, a deposit will be required prior to starting. This deposit will be applied on account until services are authorized and full payment received. Unless the insurance company denies the claim, a refund will then be issued minus any co-payments or deductibles.
8. If your insurance plan covers IVF or GIFT, we must have complete benefits and authorization directly from your primary insurance company. This must be received in our office prior to starting your medications. This is for your protection as well ours and no exceptions will be allowed. We will collect any co-payment, deductible or out-of-pocket expenses before medications begin. A detailed explanation will be given during your financial consultation.
9. For patients undergoing fertility treatment we require that all expenses incurred from a previous cycle of therapy be paid in full prior to beginning a new cycle of treatments.
10. We accept payment by cash, check, Visa, or MasterCard and request that payment be made at the time services are provided. Any co-payments, deductibles and non-covered services will be collected at the time of service for those insurance carriers that are participating providers.
11. As medical professionals, we deal ethically and honestly with every insurance provider and with every service claim we file. We will submit only for services rendered, specifically as they are rendered with the appropriate diagnosis.
It is our sincere desire to develop and maintain a strong relationship with each one of our patients. Feel free to contact our Financial Counselor or Office Manager to answer any question you may have regarding financial issues. Please do not direct any financial questions to the physician or medical staff. They will not be able to assist you in that area.
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.