First Name: MI: Last:

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1 PATIENT S INFORMATION FSAC #: TRI-COUNTY SURGERY CENTER #: (FOR OFFICE USE ONLY) (FOR OFFICE USE ONLY) First Name: MI: Last: Address: City: State: Zip: Home Phone Number: Birth Date: Age: Cell Phone Number: Alternative Phone Number: Male Female Drivers License Number: Expiration Date: Social Security Number: Marital Status: Single Married Divorced Occupation: Widow Widower Employer: Work Phone Number: Do we have permission to leave a message for you or your partner on your home, cell, alt, or work phone number?: Yes Do we have permission to release medical information to your partner?: Yes No Address: May we you or your partner s medical info, updates, and FSAC mailings to the above address?: Yes No Emergency Contact Person: Relationship to Pt.: Phone number where they can be reached: I certify that the information on this form is true and correct to the best of my knowledge, and that I will notify FSAC of any changes. I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance on my account for any services rendered. No Signature: Date: PARTNER S INFORMATION FSAC #: TRI-COUNTY SURGERY CENTER #: (FOR OFFICE USE ONLY) (FOR OFFICE USE ONLY) First Name: MI: Last: Address: City: State: Zip: Home Phone Number: Birth Date: Age: Cell Phone Number: Alternative Phone Number: Male Female Drivers License Number: Expiration Date: Social Security Number: Marital Status: Single Married Divorced Occupation: Widow Widower Employer: Work Phone Number: Do we have permission to leave a message for you or your partner on your home, cell, alt, or work phone number?: Yes Do we have permission to release medical information to your partner?: Yes No Address: May we you or your partner s medical info, updates, and FSAC mailings to the above address?: Yes No Emergency Contact Person: Relationship to Pt.: Phone number where they can be reached: I certify that the information on this form is true and correct to the best of my knowledge, and that I will notify FSAC of any changes. I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance on my account for any services rendered. No Signature: Date: Form 1015 Page 1 of 2 Revised 5/7/2014

2 Date Completed What is the primary reason for your consultation? Who referred you to our practice? Former patient Friend Lecture series Insurer (name) Internet Media article Comprehensive History Form Comments Religious issues concerning conception or infertility treatment: Medical literature Physician (name) Self referral Yellow pages Other Male Patient (name) Female Patient (name) (date of birth) age (date of birth) age Occupation Occupation Preferred Pharmacy Preferred Pharmacy Tel. #. Tel. #. Phone (day) Phone (day) (eve) (eve) (cellular) (cellular) ( ) ( ) (voice mail) (voice mail) (pager) (pager) Primary Care Physician Primary Care Physician (name) Address City State, Zip Phone Medical specialty Would you like a summary letter sent? (name) Address City State, Zip Phone Medical specialty Would you like a summary letter sent? Form 2069 Page 1 of 10 Revised

3 Duration of relationship Comprehensive History Form Duration of unprotected intercourse How long have you been actively attempting pregnancy? Contraceptive practices Intrauterine device (IUD) Oral contraceptives Other (yes) (no) (dates) Use of lubricants Douche after intercourse Painful intercourse Bleeding/spotting after intercourse Pregnancies (female): (yes) (no) Pregnancy (include all pregnancies) When? (Year) How long to conceive Gender Is current Partner the Father (Y/N) Outcome (spontaneous miscarriage, abortion, or terminations, ectopic pregnancy, vaginal delivery, cesarean section, fetal demise or stillbirth) and list complications, if any. First Second Third Fourth Fifth Male: Pregnancies from previous marriage(s) or partner(s), if any: When? (Year) Pregnancy (include all pregnancies) First Second Third Fourth How long to conceive Gender Outcome (spontaneous miscarriage, abortion, or terminations, ectopic pregnancy, vaginal delivery, cesarean section, fetal demise or stillbirth) and list complications, if any Form 2069 Page 2 of 10 Revised

4 Comprehensive History Form Female History Menstrual History Age at first menstrual period last menstrual period How often do menses occur duration of menstrual flow Amount/severity of menstrual flow Medication taken for cramps amount frequency Midcycle: spotting pelvic pain increase mucus When was your last pap smear: When was your last mammogram: Any abnormal pap smears: Do you have or have you ever had (Place a Check Mark by any that apply): Infectious Problems Gynecologic Problems Medical Problems Chicken Pox (varicella) Chlamydia Anemia Kidney disease Chicken Pox vaccine Gonorrhea Bleeding disorders Kidney infection Hepatitis A, B, or C Syphilis Blood clots Liver problems German measles-rubella Pelvic infection (PID) Blood transfusion Lost 15 pounds last year Rubella immunization Mycoplasma/Ureaplasma Diabetes Lung disease Rheumatic fever Condyloma-venereal warts Cancer Asthma Chronic bronchitis Herpes: genital Appendicitis Recurrent urinary infections Abnormal mammogram Heart disease Thyroid problems Neurological Problems Abnormal pap smear High blood pressure Arthritis Migraine headaches Blocked fallopian tubes Mitral valve prolapse Seizures (epilepsy) Pelvic adhesions Excess hair growth Other Problems: Endometriosis Hot flashes or night sweats Uterine anomalies Rh sensitized Cervical Stenosis Breast discharge DES exposure Comments Toxicant Exposure: (yes) (no) Alcohol none weekend daily Smoking Pesticides Radiation Coffee/caffeine Other chemicals (amount) Form 2069 Page 3 of 10 Revised

5 Comprehensive History Form Female History List all medication you take now (prescription, vitamin, over-the-counter, alternative therapies): (drug) (dose) (drug) (dose) Are you taking prenatal vitamins? List all allergic reactions you have had: (drug or allergen) List all surgery you have had (cervix, uterus, ovarian cysts, tubes, endometriosis, appendix, etc.): (type of surgery) (type of surgery) (type of surgery) List all other serious illnesses for which you have been under the care of a physician: (illness) (illness) Weight Height Special dietary habits: How much do you exercise? Form 2069 Page 4 of 10 Revised

6 Comprehensive History Form Family History of Female Country of origin: Mother Father Ethnic background (circle): African/American Asian Asian-Indian Caucasian Hispanic Jewish American/Indian Mediterranean Middle Eastern Other: Ethnic group (Circle all that apply) African, African/American Asian, Mediterranean or Hispanic Caucasian, Jewish Jewish Jewish Have you been tested for: Yes No Date Result Sickle cell trait Thalassemia Cystic fibrosis Tay Sachs Gaucher Are you related to your current partner (consanguinity)? Is there anyone in the family who has had any of the following illnesses: Endometriosis Excess body hair Genital abnormalities Breast cancer Chromosomal disorders Delayed development Early puberty Birth defects Bleeding disorders Yes Who Yes Who Infertility Mental retardation Early menopause < 40 yrs old Miscarriages (2 or more) Ovarian cancer Hormone disorders Metabolic disorders Genetic (inherited) disorders Comments Form 2069 Page 5 of 10 Revised

7 Comprehensive History Form Male History Growth and development: (yes) (no) Undescended testicles Delayed puberty Breast enlargement Testicular injury: (yes) (no) Varicocele Torsion (twisted) Painful swelling Severe trauma Toxicant exposure: (yes) (no) Alcohol none weekend daily Smoking Pesticides Radiation Other chemicals Sexually transmitted diseases: Chlamydia Genital warts (HPV) Gonorrhea Herpes Syphilis Other Urinary tract: Bladder/kidney infection Prostatitis Other Frequency of hot tub use: Form 2069 Page 6 of 10 Revised

8 Comprehensive History Form Male History List all medication you take now (prescription, vitamin, over-the-counter, alternative therapies): (drug) (dose) (drug) (dose) List all allergic reactions you have had: (drug or allergen) List all surgery or blood transfusions you have had: (type of surgery) (type of surgery) List all other serious illnesses for which you have been under the care of a physician: (illness) (illness) (yes) (no) Difficulty with sexual function (male): (please explain) Form 2069 Page 7 of 10 Revised

9 Male Family History Comprehensive History Form Country of origin: Mother Father Ethnic background (circle): African/American Asian Asian-Indian Caucasian Hispanic Jewish American Indian Mediterranean Middle Eastern Other: Ethnic group (Circle all that apply) African, African/American Asian, Mediterranean or Hispanic Caucasian, Jewish Jewish Jewish Have you been tested for: Yes No Date Result Sickle cell trait Thalassemia Cystic fibrosis Tay Sachs Gaucher Are you related to your current partner (consanguinity)? Is there anyone in the family who has had any of the following illnesses: Infertility Genital abnormalities Birth defects Chromosomal disorders Delayed development Early puberty Hormone disorders Pituitary tumor Lack of sense of smell Yes Who Yes Who Learning problems Mental retardation Metabolic disorders Miscarriages (2 or more) Short stature Testicular cancer Undescended testicles Abnormal breasts Genetic (inherited) disorders Comments Form 2069 Page 8 of 10 Revised

10 Comprehensive History Form Previous female infertility tests: (result) Basal body temperature Ovulation predictor kits Endometrial biopsy Post-coital test HSG Chromosome studies Hysteroscopy Laparoscopy Antisperm antibodies Pelvic ultrasound Other Immunologic screening tests: (result) ANA (antinuclear antibodies) Antiphospholipid antibodies Lupus anticoagulant Leukocyte antibody detection Thyroid antibodies Other immunologic testing Previous male infertility tests: (result) Semen analyses Post-coital test Antisperm antibodies (semen & serum) Hamster test (SPA) Chromosomes Other (SCSA, EFT, etc.) Previous hormonal tests: Female Male Result Date Result Date Testosterone Prolactin TSH FSH (random) FSH (day 3) Estradiol (day 3) DHEA-S Progesterone Form 2069 Page 9 of 10 Revised

11 Comprehensive History Form Previous Treatments: Inseminations (IUIs, without medication) Clomiphene (Clomid, Serophene) (with intercourse only) Clomiphene with inseminations (IUI) FSH * with intercourse only FSH * with inseminations (IUI) Progesterone supplements Dexamethasone, prednisone Aspirin Heparin Parlodel** - dopamine agonist IVIG Leukocyte immunization Other Yes/No # cycles Comments (dose, # days/cycle) Comments Prior in-vitro fertilization (IVF), GIFT, or intracytoplasmic sperm injection (ICSI) results, if applicable Date of procedure Procedure Protocol # of eggs obtained # of eggs mature # of eggs fertilized # embryos transferred # embryos frozen Pregnancy outcome Comments *FSH - Pergonal, Humegon, Repronex, Metrodin, Fertinex, HMG, Gonal-F and/or Follistim ** - Parlodel, dopamine agonists - bromocriptine (Parlodel), cabergoline (Dostinex) Form 2069 Page 10 of 10 Revised

12 Financial Policy The following is provided to ensure that you understand your financial responsibility prior to seeking treatment at FSAC. 1. You are responsible for obtaining prior authorization(s) from your Primary Care Physicians (PCP) and/or insurance company. Please bring authorization to your first visit or have your PCP mail or fax it to us prior to your initial consultation. We will preauthorize with your insurance carrier all surgical and hospital treatments. (initial) 2. All patients must schedule a financial consult with our financial consultant prior to starting treatment. (initial) 3. After your initial consultation, you are responsible for obtaining subsequent authorizations prior to initiating any treatment. Any services not authorized by your insurance company will be denied and will ultimately become your responsibility. Remember that a prior authorization does not guarantee benefit payment. Contact your insurance company for verification of benefits. (initial) 4. For patients using our cash packets, payment is due prior to initiating treatment. This will be discussed in detail during your financial consultation. (initial) 5. We encourage you to take an active role in understanding your insurance benefits and coverage prior to beginning any fertility treatment. No one is as interested in your insurance coverage as you are. (initial) 6. Sometimes it may take up to 4-6 weeks to obtain authorization from your insurance company. If you choose to begin treatment prior to obtaining authorization, you will be financially responsible. Insurance carriers will not retroactively authorize fertility treatment. (initial) 7. If your insurance company covers ART Treatment (IVF) we must have complete benefits and the authorization directly from your insurance carrier. We will collect any co-payments, deductibles or out-of pocket expenses before beginning treatment. (initial) 8. All past due accounts must be paid in full prior to starting a new cycle. (initial) 9. We accept payment by cash, check, MasterCard, Visa and AmEx. (initial) 10. We deal ethically and honestly with every insurance provider and with every service claim we file. We will only submit for services rendered, specifically as they are rendered with the appropriate diagnosis. (initial) 11. FSAC has professional fees (physician) and facility fees for all IVF treatment. Because the facility portion is not contracted with any insurance carriers, there is no contractual reduction or negotiated fee schedule. You will be responsible for the portion the insurance carrier does not cover. (initial) 12. When using our financial packet, please note these are discounted rates for patients who have little or no infertility coverage. I am accepting the cash package in lieu of using my insurance. I understand by using this package I am unable to, nor is FSAC able to bill the insurance carrier for reimbursement. FSAC will not make any contracted adjustments if patients knowingly submit those charges to the insurance carrier for reimbursement. (initial)

13 Eligibility Guarantee Form I, understand that I am eligible for (Patient Name) insurance benefits on or as of (Insurance Company) through my own spouse employment (Effective Date) (circle one) (Name of employer) I have chosen (Name of medical group) to be my primary medical group I understand that if the above is not true or if I am not eligible under the terms of my employer s Medical Subscriber Agreement, I (or the person financially responsible for me) am responsible for all charges related to services provided to me. In addition, I understand that all services performed at FSAC require prior authorization from my primary medical group. After initial consultation authorization, FSAC will request authorization for future treatment as indicated by the physician. However, it is ultimately my responsibility to ensure authorization has been received prior to any treatment being rendered. If prior authorization is not obtained and I received medical treatment I will be financially responsible for all related charges. Subscriber s Name Date: Signature of Patient Signature of Office Personnel Form 1029 Revised 12/27/2013

14 Assignment of Benefits, Authorization and Financial Statement I hereby authorize payment directly to Fertility and Surgical Associates of California of the surgical and/or medical benefits, if any, otherwise payable to me for the services as described on the attached claim. I hereby authorize Fertility and Surgical Associates of California to release any medical information during the course of my examination and treatment to my insurance company, pharmacy, or laboratory as necessary. I realize that I am responsible for payment in full of the charges on my account for services rendered to me by Fertility and Surgical Associates of California. By signing this agreement, I acknowledge that I have read, understand and agree to the terms of the above policy in its entirety. Date: Signature of Patient (or Legal Guardian) Printed Name FORM 1030 REVISED 12/27/2013

15 HIPAA Privacy Rule Individual Consent Agreement Consent to Use and Disclosure of Protected Health Information For Treatment, Payment, or Healthcare Operations ( (a)) I, understand that as part of my health care, Fertility and Surgical Associates of California Inc., originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. I understand that this information serves as: A basis for planning my care and treatment; A means of communication among the health professionals who may contribute to my health care; A source of information for applying my diagnosis and surgical information to my bill; A means by which a third-party payer can verify that services billed were actually provided; A tool for routine health care operations such as assessing quality and reviewing the competence of the health care professional. I have been provided with and understand that Fertility and Surgical Associates of California Inc. s Notice of Privacy Practices provides a more complete description of the information. I understand that: I have the right to review Fertility and Surgical Associates of California, Inc., Notice of Privacy Practices prior to signing this consent; That Fertility and Surgical Associates of California, Inc., reserves the right to change their notice and practices prior to implementation and will mail a copy of any revised notice to the address I have provided; I have the right to object to the use of my health information for directory purposes; I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that Fertility and Surgical Associates of California, Inc., is not required by law to agree to the restrictions requested. I may revoke the consent in writing at any time, except to the extent that Fertility and Surgical Associates of California, Inc., has already taken action in reliance thereon. I request the following restrictions to the use or disclosure of my health information: [ ] Accepted [ ] Denied Date: Signature of Individual or Legal Representative Witness: Social Security Number: Date of Birth: Printed Name of Individual or Legal Representative Witness: Form 1031B Revised 12/27/2013

16 Authorization for the Disclosure of Protected Health Information (Medical Records) for Treatment, Payment, or Healthcare Operations ( (a)) HIPAA Privacy Rule Individual Authorization Agreement I,, understand that as part of my health care, Fertility & Surgical Associates of California (FSAC) originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. I understand that this information serves as: a basis for planning my care and treatment; a means of communication among the health professionals who may contribute to my health care; a source of information for applying my diagnosis and surgical information to my bill; a means by which a third-party payer can verify that services billed were actually provided; a tool for routine health care such as assessing quality and reviewing the competence of health care professionals I understand that Fertility & Surgical Associates of California s Notice of Privacy Practices provides a more complete description of the information uses and disclosures. I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review Fertility & Surgical Associates of California s Notice of Privacy Practices prior to signing this authorization. PHI Authorized: Medical records/information pertaining to medical history, mental or physical condition, services, rendered, or treatment, including ultrasound results, ovarian stimulation flow sheets, operative reports, laboratory studies, medical and/or billing information as indicated for medical care by FSAC. I authorize the release of my Protected Health Information (PHI): FROM: (Name & Address) TO: (Name & Address) (Fax number if applicable <5 pages) (Fax number if applicable <5 pages) I understand that: I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations by other covered entities; Information to be restricted Length of time and reason for restriction I may revoke this consent in writing at any time, except to the extent that Fertility & Surgical Associates of California has already taken action in release of my PHI as indicated above. [X] Accepted [ ] Denied Printed Name of Patient or Legal Representative: Signature of Patient or Legal Representative: Last 4 Digits of Social Security Number: Date of Birth: Today s Date: Patient s Current Contact Phone Number: Fertility & Surgical Associates of California Tel (805) / FAX: (Medical Records Dept.) 325 Rolling Oaks Drive, Suite Balboa Boulevard, Suite 312 Thousand Oaks, CA Encino, CA Form Release