INSURANCE RELEASE FORM

NORTHERN FERTILITY & REPRODUCTIVE ASSOCIATES, P.C.
and
REPRODUCTIVE TECHNOLOGIES LAB., INC.

It is our office and Lab policy to bill your insurance carriers as a courtesy to you for all office, laboratory and surgical services rendered. This policy in no way alleviates your responsibility for payment in full. All other patient services, such as office visits and/or supplies, are payable at each visit. Any unpaid balances after your insurance carriers have paid their portion will be due in full from you within thirty (30) days, unless arrangements have been made with our Billing Department. This includes any denied or expired insurance claims.

I have read, understood and agreed on the above policies of Northern Fertility & Reproductive Associates, P.C. and Reproductive Technologies Lab., Inc.

SIGNATURE: _____________________________ DATE: _____________

PATIENT'S CERTIFICATION, AUTHORIZATION TO RELEASE INFORMATION AND PAYMENT REQUEST

I hereby authorize Northern Fertility & Reproductive Associates, P.C., and Reproductive Technologies Lab., Inc., to submit any claims to my insurance carrier or intermediaries for all covered services rendered and authorize and direct my insurance carrier or its intermediaries to issue payment check(s) directly to them.

I authorize Northern Fertility & Reproductive Associates, P.C., and Reproductive Technologies Lab., Inc., to furnish complete information to my insurance carrier or its intermediaries regarding services rendered.

SIGNATURE: _____________________________ DATE: _____________

Abington Office: Abington Court Apartments, 1300 Old York Road Abington, PA 19001,
Holy Redeemer Office: Holy Redeemer Office Building E-4 1650 Huntingdon Pk., Suite 154, Meadowbrook, PA 19046