New Patient Documents

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Patient Documents

The following are documents for HRC Fertility patients in downloadable PDF format.

New Patient Forms

Patient Registration Form
This form is used to gather basic registration information about you and your partner.

Release and Assignment
This standard release allows us to provide information to your insurance company for billing and reimbursement purposes.

Request for Limitations and Restrictions of Protected Health Information
This form documents and verifies the best way to communication with you (HIPAA compliant).

Receipt of Notice of Privacy Practices Written Acknowledgment Form
This document acknowledges that you have received HRC Fertility’s Notice of Privacy Practices

Financial Policy
This information ensures that patients understand their financial responsibility prior to seeing treatment at HRC Fertility.

Insurance Authorization
This document authorizes payment to HRC Fertility from your health insurance company.

Medical Records Request
This optional release allows HRC Fertility access to your medical records related to infertility or gynecological medical problems.

Patient Acknowledgment
This document outlines patients’ rights and responsibilities, physician ownership disclosure, advance directive policy and the grievance policy.

Patient Acknowledgment Signature Sheet
Signature on this document is required at least one day before surgery to confirm that patient has received the Patient Acknowledgement document.

New Patient Information

Preconception Guidelines
HRC Fertility has assembled a list of guidelines and testing recommendations for all patients who are trying to conceive.

What to Expect
This document outlines what to expect during your initial consultation with HRC Fertility

Notice of Privacy Practices
This notice describes how health information about you, as a patient of this practice, may be used and disclosed, and how you can get access to your individually identifiable health information.

We are proud to report that as a result of our treatments several thousand babies have been born across the United States and around the world.