INTAKE FORM FOR OUTSIDE CLINIC SERVICES v3/23

Intake Form for Outside Clinic Services

Your insurance may, or may not, cover infertility services. Under your insurance plan, you are financially responsible for all co-payments, co-insurances, and deductibles. You are also financially responsible for and will not be entitled to insurance discounts for all non-covered services or services that exceed your benefit limits or maximum benefits. For insurance benefits and coverage questions, please contact your insurance directly. A decision of covered or non-covered services is determined by your insurance provider in accordance with your insurance plan.
A co-management fee of $350 needs to be paid prior to any appointments being scheduled (this fee is non-refundable)
Legal name of patient/donor*
Address*
Home Phone*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Email Address*
example@example.com
Date of birth*

MonthDayYear
Date
Insurance

(Do not provide insurance if you are a Gestational Carrier or Donor. Put 'N/A' in required fields.)
Insurance Carrier Name*
Insurance Carrier Group #*
Insurance Carrier ID#*
Insurance Phone#*
Medical Clinic

(where IVF services are being completed)
Name of Medical Clinic*
Clinic Phone*
Clinic Fax*
Clinic Address*
Clinic Contact Name*
Ordering MD*
Agency

(complete if you are a donor or Gestational Carrier working with an agency)
Name of Agency*
Agency Address*
phone*
Contact person*
Billing
Name of responsible party*
Address*
Phone Number*
Please enter a valid phone number.
G:ElectronicDocuments/235

3/23/23
Upload/Take photo of the FRONT of your insurance card
Upload/Take photo of the BACK of your insurance card
Should be Empty:

Intake Form for Outside Clinic Services

A co-management fee of $350 needs to be paid prior to any appointments being scheduled (this fee is non-refundable)

Insurance

Medical Clinic

Agency

Billing