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Financial Information
Currently, most health insurance plans do not cover
assisted reproductive technologies. Although insurance coverage may
be available for pre-IVF evaluation, most plans that exclude IVF treatments
will exclude visits, procedures, tests and laboratory studies in preparation
for an IVF treatment cycle. However, plans vary widely and you should
check your individual policy or call your insurance company to determine
if, and to what extent, these procedures are covered. If you do
not have insurance coverage, submitting charges to your insurance
company for reimbursement may constitute fraud.
 NO INSURANCE COVERAGE
FOR IVF
| ____ |
____ |
We understand that if we are covered by an insurance
plan that does not cover assisted reproductive technology or
we do not have insurance, a pre-paid IVF fee of $12,875 is required.
This payment must be received by GRS no later than the date
that the first IVF medication is initiated. The pre-paid IVF
fee will cover the following medical care to be provided during
our IVF cycle: |
- Cycle monitoring visits including ultrasounds, office visits and labs
- Physician, anesthesia & embryology professional fees
- Laboratory and medical supplies associated with egg retrieval and embryo transfer
- Cryopreservation of embryo(s)
- One year of embryo storage
Payment for charges not covered by the pre-paid IVF fee will be expected at the time that these services are rendered. These services include:
| - New patient evaluation |
- Pre-cycle office visits |
| - Pre-cycle ultrasounds |
- Medication |
| - Pre-cycle laboratory testing |
- Counseling or teaching visits |
| - Pregnancy testing |
- Pregnancy ultrasounds |
| - Embryo biopsy |
|
| ____ |
____ |
We understand that we may not request a refund after starting ovulation induction treatment. However, if the cycle is cancelled due to poor response or other reasons determined by the physician and retrieval is not performed, GRS will make an itemized accounting of charges and determine whether a refund is due. If a refund is due, the balance amount may be applied to the next IVF cycle. If the egg retrieval is performed but we do not have the embryo transfer, we will receive a refund of $500.
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LIMITED INSURANCE COVERAGE FOR IVF
| ____ |
____ |
We understand that
we may wish to submit charges to our insurance company for consideration
of reimbursement and that we may submit copies of the daily
encounter form. The insurance company may directly reimburse
us for any covered procedures. If a predetermination of
benefits indicates that insurance coverage for IVF is not available,
any subsequent insurance payments received by Georgia Reproductive
Specialists will be returned to the insurance company. |
WHEN
INSURANCE COVERAGE HAS BEEN DOCUMENTED
Georgia Reproductive Specialists has received verification from your insurance company indicating that coverage for the proposed Assisted Reproductive Technology Procedures are presently covered under the terms of your current medical policy. Benefits are provided only if the coverage is still in effect at the time the services are rendered.
Co-pay amount_______ Co-insurance amount_______Other________
Your insurance plan has a maximum
infertility lifetime benefit of $_______ of which $_______ has been
paid to date.
Your insurance plan has an out-of-pocket maximum of
$_______.
| ____ |
____ |
We understand that we are responsible for payment of any deductible amounts included in my plan. These payments are due at the time of service. |
| ____ |
____ |
We understand that we are responsible for payment of the following non-covered services: Anesthesia ($500), cryopreservation of embryo(s) ($515), storage of embryo(s) for six months ($257). |
| ____ |
____ |
We understand that in order to be successful, IVF requires timely access to laboratory studies performed by techniques that may not be available through the laboratory contracted with our managed care company. Therefore, we may be asked to pay for certain laboratory tests needed to monitor treatment and determine the optimal time to retrieve the eggs. |
| ____ |
____ |
We understand that we are responsible for any charges that were pre-approved by our insurance company but were subsequently denied due to change of benefits, exceeding coverage limits, or any other cause.
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| ____ |
____ |
We understand that if we choose to attempt a subsequent fresh IVF cycle before insurance payment has been made to GRS for the prior cycle, we will be responsible for medical expenses incurred for the subsequent cycle. A total pre-paid fee of $12,875 would be required to begin a subsequent fresh cycle using donor egg. GRS will file my insurance claims and make appropriate patient refunds once reimbursement is received.
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This agreement is valid for 30 days from the date below. We have met with the financial counselor at Georgia Reproductive Specialists and fully understand and accept our financial obligations.
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by IVF.com,
Atlanta, GA, USA.
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