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By submitting this form, you agree to our Privacy Policy and Terms of Use and consent to receive occasional messages from RSMC.
This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.
You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.
I voluntarily request a physician, and/or mid level provider (Nurse, Medical Assistant, etc.), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).
I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents
This statement describes your financial responsibilities as a patient at RSMC Fertility. Please direct any questions you may have to our Finance department.
Patient is responsible for payment of known deductibles, coinsurance, copayments, non-covered services, or ART cycle (IVF, Donor Egg, and FET) at or before the time of service.
Balances that are unknown at the time of service will be billed to the patient. Patients are responsible for the prompt payment of these balances. Balances not paid within 30 days will be subject to finance charges.
A fee of $25.00 will be assessed for each returned check.
Patients are responsible for all fees associated with or incurred due to nonpayment of account. These fees include, but are not limited to collection agency, legal and court fees.
Patient is responsible to verify insurance benefits and to ensure appropriate insurance authorizations, pre-certifications and referrals are obtained prior to services being rendered. RSMC Fertility Financial Counselors are available to assist in this matter, however, failure to do so will result in the patient’s financial responsibility for non-authorized services
FINANCIAL COUNSELORS ARE AVAILABLE TO PROVIDE ADDITIONAL INFORMATION
My signature below indicates that I have read and understood the above Financial Policy:
This statement is to confirm that I have opted to see Dr. Ho, Dr. Freije and/or Dr. Harari and will be personally held responsible for the cost of services he renders.
I understand that if my insurance requires a referral then it must be obtained before I can be seen as a patient:
If my insurance carrier requires a referral and it is not obtained, then my appointment will be rescheduled.
If the insurance company denies my referral, then I will be responsible for the payment of all services.
Email us at family@fertile.com if you have any questions before signing up for a consultation. Our expert team is happy to assist you.
