INSURANCE
RELEASE FORM
NORTHERN FERTILITY & REPRODUCTIVE ASSOCIATES, P.C.
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: _____________
This
Insurance Release Form can be printed out so that you can
sign it and bring it in when you visit.
*PRINTER-FRIENDLY
FORM CLICK HERE
