CRM Authorization Form

Privacy Notice

I understand that I have been provided the CRM/ART Privacy Notice and to make any specific restrictions to the release of my Protected Health Information prior to signing this consent.

Consent to Release Medical Records to Other Providers

I consent to the release of information about my medical condition to any healthcare provider also involved in my care. In the event a healthcare worker is exposed to my blood or other body fluids, results of STD testing and other medical records can be released to the healthcare worker's medical provider. My consent continues until I (or my authorized representative) revoke or limit it in writing.

Assignment of Benefits and Related Release of Information

I request payment of authorized benefits directly to the provider for services provided to me by the Center for Reproductive Medicine, P.A. (CRM) I authorize release of medical and other information about me to my insurance company, HMO, other third party payers, or their third party administrators, in order to process and pay claims, determine benefits; perform quality of care reviews or for healthcare operations. I may revoke this consent for release of information by written notice, but my revocation will not apply to information already released.

Guarantee and Agreement to Pay

I agree to pay the charges for the care and treatment rendered to me not covered by my insurance plan or in the absence of insurance coverage (or, if signed by someone other than the patient, to guarantee payment for the care and treatment rendered to the patient named on this document). I understand that interest may be added if the account balance goes to a collection agency. Insurance Coverage Center for Reproductive Medicine (CRM) vs. Advanced Reproductive Technologies (ART) I understand that the CRM has two identities. CRM accepts insurance reimbursement for covered services. (Ultrasound, Lab and office visits for IVF monitoring are billed by CRM and may not be covered by insurance if IVF is not a covered service.) ART accepts insurance reimbursement from some insurances for IVF, Donor IVF, Gestational Carrier, and associated services when these services are covered by my insurance. I understand I will be provided with forms to file to my insurance carrier if ART is a non-participating provider. I understand I may receive insurance reimbursement directly from my insurance carrier only if I have out of network benefits. I will be notified of these fees in advance of proceeding with services and be responsible for payment of these services in advance.

Regulatory Reporting (SART)

I consent to the release of information to CRM/ART regarding my pregnancy and delivery for the purpose of required data collection.

Consent for the Use of Medical Records in Research

I authorize this facility to release my medical record, which includes all of my visits to this facility, for research purposes. This authorization continues until I (or my authorized representative) revoke or limit it in writing. This facility will keep my medical record information confidential.

Permission to verbally discuss PHI

I give permission to Center for Reproductive Medicine (CRM) and Advanced Reproductive Technologies (ART) to leave a voicemail message for me at the following numbers listed below:

Cell     Home     Work    
Cell     Home     Work    

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