Emergency Information: List nearest relative preferable not living with you.

Transcription

1 Patient Information Label Last Name First Name M.I. Maiden or Nickname Street Address Apt. P.O.Box City State Zip Social Security # XXX- X - (last five) Birth / / Marital Status!Single!Married!Divorced!Widowed!Other Home Phone# ( ) - Work Phone # ( ) - Ext. Cell Phone # ( ) - E- Mail Address May we you?!yes!no Partner completes next page Male / Female (circle one) Primary Care Physician s Name: Town: Patient s Employer Information Employer Name or Student (please circle) Occupation: Insurance Information Primary/Secondary Primary Insurance Company Name ID # Group # Copay $ Phone Please indicate the policyholder for the primary insurance! Self! Parent! Spouse! Other Subscriber Information: (If different than above) Name Birth / / Social Security # XXX- X - Employer Employer s Phone # ( ) - Secondary Insurance Company Name ID # Group # Copay $ Phone Please indicate the policyholder for the secondary insurance! Self! Parent! Spouse! Other Emergency Information: List nearest relative preferable not living with you. In case of an emergency, we may contact: Telephone # ( ) - Relationship to Patient Authorization for Treatment, Payment & Healthcare Operations I authorize the release of medical information for purposes of treatment, payment and healthcare operations. Additionally, I authorize and assign any payment of medical benefits to the Center for Advanced Reproductive Services, P.C., its successors and assign, or any individual it may designate for services provided. As part of this authorization, Center for Advanced Reproductive Services, P.C., will release HIV, Drug and Alcohol, and Mental Health/Psychiatric information as required by law. I further agree to pay all costs of collection, including attorney s fees, associated with collection of any amount due for services rendered. I will pay interest at the prevailing annual rate for all amounts 30 days past due. I understand that I am financially responsible to the Center for Advanced Reproductive Services, P.C., its successors and assigns and any individual it may designate for amounts owed by me in accordance with my health benefit coverage. Signature of Patient or Parent of Minor Notice of Privacy: " Accepted " Refused Signature of Patient or Parent of Minor

2 Partner Information Label Patient completes previous page Last Name First Name M.I. Maiden or Nickname Street Address Apt. P.O.Box City State Zip Social Security # XXX- X - (last five) Birth / / Marital Status!Single!Married!Divorced!Widowed!Other Home Phone# ( ) - Work Phone # ( ) - Ext. Cell Phone # ( ) - E- Mail Address May we you?!yes!no Male / Female (circle one) Primary Care Physician s Name: Town: Partner s Employer Information Employer Name or Student (please circle) Occupation: Insurance Information Primary/Secondary Primary Insurance Company Name ID # Group # Copay $ Phone Please indicate the policyholder for the primary insurance! Self! Parent! Spouse! Other Subscriber Information: (If different than above) Name Birth / / Social Security # XXX- X - Employer Employer s Phone # ( ) - Secondary Insurance Company Name ID # Group # Copay $ Phone Please indicate the policyholder for the secondary insurance! Self! Parent! Spouse! Other Emergency Information: List nearest relative preferable not living with you. In case of an emergency, we may contact: Telephone # ( ) - Relationship to Patient Authorization for Treatment, Payment & Healthcare Operations I authorize the release of medical information for purposes of treatment, payment and healthcare operations. Additionally, I authorize and assign any payment of medical benefits to the Center for Advanced Reproductive Services, P.C., its successors and assign, or any individual it may designate for services provided. As part of this authorization, Center for Advanced Reproductive Services, P.C., will release HIV, Drug and Alcohol, and Mental Health/Psychiatric information as required by law. I further agree to pay all costs of collection, including attorney s fees, associated with collection of any amount due for services rendered. I will pay interest at the prevailing annual rate for all amounts 30 days past due. I understand that I am financially responsible to the Center for Advanced Reproductive Services, P.C., its successors and assigns and any individual it may designate for amounts owed by me in accordance with my health benefit coverage. Signature of Patient or Parent of Minor Notice of Privacy: " Accepted " Refused Signature of Patient or Parent of Minor

3 Place patient label here NEW PATIENT INTAKE RECORD The Center For Advanced Reproductive Services Referring MD Address Name: of Birth: Age: Occupation: Ethnic extraction: Ht: Wt: Single Married Divorced Committed relationship Previous Marriages: Yes No If yes, date of divorce: Partner s Name: of Birth: Age: Partner s Occupation: Duration of marriage/committed relationship: Why would you like to be evaluated? Infertility, duration Endometriosis Excessive hair growth or loss Irregular or abnormal periods Recurrent miscarriages Premature menopause Other AREA IN BOX FOR OFFICE USE ONLY TO BE COMPLETED BY PHYSICIAN Chief Complaint(s): Hx of Present Illness: (location, duration, sererity, quality, context, modifying factors, associated symptoms) MENSTRAL HISTORY: Age of onset: Interval: Duration: (# of days between 1 st day of 1 period & 1 st day of next period) (# of days of flow) Flow: Scant Pain: Mild to none Moderate Heavy Moderate Severe Medication for cramps: Last menstrual period: Previous menstrual period: Mid-cycle bleeding or spotting: Yes No Bleeding after intercourse Yes No Vaginal discharge: Premenstrual symptoms: OBSTETRICAL HISTORY: Number of times you have been pregnant (including miscarriages and abortions)? 1 st preg Year Outcome* Infertility Therapy? How long to conceive? Complications Sex WT Preterm? 2 nd preg 3 rd preg 4 th preg * V = Vaginal Delivery; C/S = C/Section; M = Miscarriage; A = Abortion; EP = Ectopic Pregnancy

4 Family History and Genetic Questionnaire Patient Name: Partner Name: : Please answer the following medical history questions about yourself, your partner and your relatives. Please consider all family members related to you or your partner by blood including parents, grandparents, siblings, half- siblings, nieces, nephews, aunts, uncles, cousins, and any children you have had together and/or with previous partners. Have any of the following conditions occurred in your family? Check yes if the condition has occurred in you, your partner and/or Any of your relatives. Please specify how the person is related to you or your partner (for example, grandmother, aunt, son, etc) and any details you know about the condition. Additional space is provided below. Open Spine defect (e.g. spina bifida, anencephaly) Heart defect Cleft lip and/or palate Other birth defects Chromosome condition (e.g. translocation carrier, Down syndrome) Blood disorder (e.g. sickle cell anemia, thalassemia, hemochromatosis) Bleeding disorder (e.g. hemophilia) Neuromuscular disease (e.g. muscular dystrophy) Cystic Fibrosis Adult onset neurological disorder (e.g. Huntington disease) Fragile X syndrome Other inherited or genetic condition Mental retardation Development delay, autism or learning difficulties Relative who died suddenly before age 50 years (not from accident) Kidney disease at a young age (before age 40 years) Cancer (before age 50 years) Three or more miscarriages A still born baby or a baby that died with the first year Premature menopause (before age 40 years) Infertility Any other family history that is of concern? (Please specify below) Female and her family members Yes Specify who # in the family Male and his family members Yes Specify who # in the family For any of the above answered yes, please specify the condition. List who has the condition (you, your partner or how they are related to you or your partner), the approximate age that the condition was diagnosed, and any details about the condition that you know: Are you and your partner related by blood? (Circle) Yes No Unsure If yes, how are you related?

5 Some genetic conditions occur more commonly in certain racial or ethnic groups. Please answer the following questions about you and your partner s ethnic background and any genetic testing or carrier screening either of you has had. Ancestry: Female Partner Are you or any of your blood relatives (Check all that apply) Caucasian? Yes Have you had carrier testing for No Yes Unsure If you have had testing, when and what were the results? Result From Italy, Greece, India or the Middle East? Thalassemia? From Southeast Asia, Taiwan, China, or the Philippines? Thalassemia? African/African American or Hispanic? Sickle- cell trait? French Canadian? Tay- Sachs disease? Ashkenazi Jewish? Canavan disease? Tay- Sachs disease? Ancestry: Male Partner Are you or any of your blood relatives (Check all that apply) Yes Have you had carrier testing for No Yes Unsure If you have had testing, when and what were the results? Result Caucasian? From Italy, Greece, India or the Middle East? Thalassemia? From Southeast Asia, Taiwan, China, or the Philippines? Thalassemia? African/African American or Hispanic? Sickle- cell trait? French Canadian? Tay- Sachs disease? Ashkenazi Jewish? Canavan disease? Tay- Sachs disease? Have you or your partner had any genetic testing not listed above? (circle) Yes No Unsure If yes, Please specify who had the testing, what the test was for and the result:

6 Name: T0#: : SEXUAL HISTORY: How often do you have intercourse in a month? How often during ovulation? Is intercourse painful? Yes No Do you use lubricant? Yes No Do you douche? Yes No How would you describe your sex drive? Satisfaction (comments): Have fertility issues changed this? Yes No Form(s) of contraception used in past: HISTORY OF FEMALE FERTILITY THERAPY: Have you been evaluated or treated for infertility before? Yes No Physician: Duration of infertility: What cause of infertility was determined? Check all prior infertility testing that you have had performed and indicate results: Basal body temperature charts (BBT s): Hormonal assays (FSH, LH, prolactin, estrogen, DHEA-S, testosterone, progesterone): Endometrial biopsy: Hysterosalpingogram (x-rays of the uterus & tubes): Ultrasound: Laparoscopy: Mycoplasma, Chlamydia, Gonorrhea cultures: Thyroid tests: Chromosomes: Other FEMALE MEDICAL HISTORY: Do you have or have you ever had any of the following? Abnormal pap smear Yes No Heart disease/disorder Yes No Anemia Yes No Immunization, German Measles Yes No Arthritis Yes No Kidney/bladder disease Yes No Asthma Yes No Liver disease/hepatitis Yes No Anxiety disorder Yes No Loss of balance Yes No Blood/Bleeding disorder Yes No Muscle aches/joint pains Yes No Blood transfusion Yes No Neurological problems Yes No Breast problem/disorder Yes No Ovarian infection Yes No Cancer (specify below) Yes No Poor sense of smell Yes No Colitis Yes No Psychiatric illness Yes No Color Blindness Yes No Respiratory disease/disorder Yes No Diabetes Yes No Seizures Yes No Eating disorder Yes No Thyroid problem Yes No Endometriosis Yes No Ulcer Yes No Epilepsy Yes No Urethral discharge Yes No Excessive hair growth Yes No Vaginal or pelvic infection Yes No Gallbladder disease Yes No Venereal disease Yes No High blood pressure Yes No Weakness/fatigue/dizziness Yes No Other: Comments: Allergies to medications: (list all with reactions): Current medications: (list all including vitamins & herbal supplements) Amount of: Caffeine: /day Cigarettes: /day Alcohol: /week Drugs: Exercise: / day or week

7 Name: T0#: : Self breast exam No Yes how often Did your mother take DES when she was pregnant with you? Yes No Have you ever been hospitalized or had surgery? Yes No Specify reason for admission: Other: FAMILY HISTORY: Is there family history (includes parents, grandparents & siblings only) of any of the following? Infertility Yes No Pregnancy Losses Yes No Endometriosis Yes No Diabetes Yes No Bleeding Disorders Yes No Early Menopause Yes No Breast or Ovarian Cancer Yes No High Blood Pressure/Stroke Yes No Is there a family history (for all blood relatives of both partners) of any of the following? Your blood relatives Partner s blood relatives Birth defects Yes No Yes No Chromosonal defects Yes No Yes No Cystic Fibrosis Yes No Yes No Down s Syndrome Yes No Yes No Mental Retardation Yes No Yes No Open spine defects Yes No Yes No Sickle cell anemia Yes No Yes No Thalassemia Yes No Yes No ANCESTRY Asian Yes No Yes No Mediterranean Yes No Yes No Ashkenazi Jewish Yes No Yes No French Canadian Yes No Yes No African descent Yes No Yes No FAMILY TREE: TO BE COMPLETED BY PHYSICIAN

8 Name: T0#: : MALE PARTNER S HISTORY: Ht: Wt: Ethnic extraction: Previous Marriage: Divorce : Previous Children or Pregnancies Caused: Allergies to medications: Current medications: (include vitamins & herbal supplements): Illnesses: Surgery in pelvic area: Yes No (i.e. variocele repair, vasectomy, vasectomy reversal or repair) Other surgeries: X-rays of pelvic area? Yes No If yes, specify: Are you or have you ever been exposed to any of the following: Extreme heat Chemicals Toxic Fumes Nuclear radiation Have you had a fever over 102ºF during the past 3 months? Yes No Do you frequently take saunas or steam baths? Yes No Amount of: Caffeine: /day Cigarettes: /day Alcohol: /week Drugs: Exercise: / day or week Have you ever had Mumps? Yes No Age: Do you have any trouble getting an erection? Yes No Maintaining an erection? Yes No Do you feel that most of your ejaculate is deposited in the vagina? Yes No Do you ever have orgasms without ejaculation during masturbation? Yes No How is your sexual drive? Any recent changes: Yes No Have you been evaluated or treated for infertility before? Yes No Physician: Duration of infertility: Have you had semen analyses? Yes No If yes, specify date(s) & results: What cause of infertility was determined? Have you taken any drugs for infertility? Yes No If yes, specify: MALE MEDICAL HISTORY: Do you have or have you ever had any of the following? Arthritis Yes No Neurological problems Yes No Asthma Yes No Parasitic infection Yes No Blood transfusion Yes No Prostatitis Yes No Breast discharge Yes No Rash or sores on penis Yes No Cancer (specify below) Yes No Seizures Yes No Cystic Fibrosis Yes No Testes infection Yes No Diabetes Yes No Testes injury Yes No Heart disease/disorder Yes No Testes tumor Yes No High blood pressure Yes No Thyroid problem Yes No Kidney infection Yes No Urethral discharge Yes No Liver disease/hepatitis Yes No Venereal disease Yes No Other: Comments: KW Revision 03/07

9 IMPORTANT INSURANCE INFORMATION Before your first visit.. If your insurance requires a referral from your Primary Care Physician, please be sure to obtain one before your first visit. Any co-payment required by your insurance will be collected on the day of your appointment. If your insurance company does not participate with The Center for Advanced Reproductive Services, or if you do not have covered benefits for your services, you will be expected to pay at the time services are provided. The Center participates with the following insurance companies: Aetna, Anthem BCBS, Empire BCBS, Cigna, Connecticare, First Health Network/Coventry Health, Harvard Pilgrim Healthcare, Healthy CT, Multiplan/ PHCS, One Health/Great West, Oxford, United Health, Yale Health Plan It is your responsibility to inform your Financial Service Representative (FSR) when there a change in your insurance plan, or there is a change in your treatment plan. Questions regarding your insurance should be directed to the following Financial Service Representative depending on the doctor you are seeing at The Center. PLEASE CONTACT: Farmington Office All services being rendered by Claudio Benadiva, M.D. - Christine: (860) , ext 8021 All services being rendered by John Nulsen, M.D. - Sue D: (860) , ext 8015 All services being rendered by David Schmidt, M.D. Veronica (860) , ext 8031 All services being rendered by Lawrence Engmann, M.D. (Farmington Patients Only) Denise (860) ex 8061 Hartford Office All services being rendered by Lawrence Engmann, M.D. Jeannette: (860) , ext All services being rendered by Andrea Diluigi, M.D. Amanda W: (860) , ext 8103 Specialized Programs AED, IED, and Gestational Carrier Programs- Dawn: (860) , ext 8014 PGD and PGS Programs - Christine: (860) , ext 8021 *This information is subject to change. Please contact your FSR for updates updated 8/16.. clh

10 THE CENTER FOR ADVANCED REPRODUCTIVE SERVICES The Center Farmington / Hartford / New London Thank you for choosing The Center. We are committed to your treatment being as pleasant and stress free as possible. OUR FINANCIAL AGREEMENT The following is a statement of our Financial Policy, which we require you to read and sign prior to services being rendered. Please understand that payment of your bill is considered part of your treatment. REGARDING INSURANCE As a courtesy to you, we accept assignment insurance benefits from the following insurance companies once a benefit has been determined: *List of participating insurance companies subject to change.* *Aetna *Anthem Blue Cross & Blue Shield *Cigna *Connecticare *Empire Blue Cross & Blue Shield *First Health/Coventry Health Care *Harvard Pilgrim *Healthy CT *Multiplan/PHCS *One Health/Great West (now Cigna) *Oxford Health Plan *United Health Care *Yale Health Plan Your insurance policy is a contract between you and your insurance company. We are NOT a party to that contract. All contracts have limits and/or various levels of co-payments. Please make yourself aware of your specific plan design. In most cases you can discuss this with your human resources department or call the number on your insurance card for details. The treatment recommended by our office(s) is never based on what your insurance(s) will pay; it is base upon our dedication to giving our patients the highest quality of care. IT IS THE PATIENTS RESPONSIBILITY TO INFORM THE OFFICE OF ANY INSURANCE CHANGES. We have a team of financial counselors to assist you. They will work with you and your health plan to provide information and any documentation that may be required. We will do our best to estimate what your patient portion will be for your services; this is based on the information given to us by your insurance company. This estimated amount is due up front and should NEVER be considered a guarantee that your insurance will cover the remainder. The balance is ultimately your responsibility whether your insurance company pays or not. Payments on all patient balances are required prior to services. We accept CASH, CHECK, DISCOVER, MASTERCARD, VISA and AMERCIAN EXPRESS. In the event your account is turned over to collections or an attorney, you will be responsible and hereby agree to be responsible for all associated fees. The court will determine attorney s fees where an attorney on behalf of The Center for Advanced Reproductive Services brings legal action. *PLEASE SIGN AND DATE BOTH STATEMENTS AFTER YOU HAVE COMPLETED READING OUR POLICY. I HAVE READ IN FULL THE FINANCIAL STATEMENT SET FORTH Signature of Patient or Responsible Party I UNDERSTAND AND AGREE TO THE FINANCIAL POLICY SET FORTH Signature of Patient or Responsible Party 06/25/2015

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