South Sound Vasectomy

Insurance Information
Will you be using insurance?*

YesNo
Employer
Insurance Company
Is this Tricare?

YesNo
For Tricare, please provide the 11 digit Benefits Number found on the back of your DOD card.
Policy# or Insured/Member ID
Provider Customer Service Phone #
Group#
Name of policy holder
Relationship to policy holder
Do you have secondary insurance?*

YesNo
Secondary Insurance Company
Secondary Policy# or Insured/Member ID
Secondary Provider Customer Service Phone #
Group#.
Name of policy holder.
Relationship to policy holder.

Confirmation and Attestation Page
Please review the below pre-vasectomy instructions.

Pre-vasectomy Instructions
Please review the below post-vasectomy instructions.

Post-vasectomy Instructions
Please review the below privacy policy.

SSV HIPAA form
Please review the below financial policy.

SSV financial form
I have read and understand my doctor's vasectomy information page, which includes the FAQs, the HIPAA form, financial agreement, as well as the instructions to be followed before and after the vasectomy. I also confirm that all of the information I have provided is accurate.*

Yes
By signing I agree to the above.*

Insurance Information