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Patient Consent Form

Patient Consent Form

INSURANCE AND FEE POLICIES

Boca Fertility will bill your insurance for covered charges incurred in our office. Your deductible and copayment are due at the time of your visit. We accept cash, MasterCard, Visa, or Discover. Patients paying cash should note that we do not keep change in our office. (If you do not have the exact amount, we can either credit your account for the overpayment or mail you a check.)

Boca Fertility verifies your insurance benefits with your insurance company prior to your appointment. Please be aware that it is only an ESTIMATION of benefits, it is not binding by the insurance company and is subject to approval by your insurance. You will be responsible for all charges not paid by your insurance company. Self pay balances and embryo/sperm/egg storage fees will be charged to your credit card regardless of the reason.

Some services provided by our office may be non-covered. If we have been informed that the service is not covered you will be responsible for payment in full at the time of the visit. Otherwise, we will file the claim and bill you if it is denied.

Many insurance policies do not cover infertility; therefore, your expenses at our office may not be covered.

If your insurance coverage is terminated or you switch policies, it is your responsibility to let us know prior to receiving further services.

It is possible at some point your insurance company may request a copy of your records to determine if your treatment is for a non-covered or pre-existing condition. Unfortunately, this is a matter we have no control over. We cannot withhold or alter records.

For surgery, ovulation induction therapy, and in vitro fertilization, we will bill your insurance; subject to verification of coverage and pre-payment of your expected out-of pocket expenses. You will be billed for all charges not paid by your insurance. Patients with accounts sent to an outside collection agency are responsible for all collection costs and legal fees.

The medical personnel in our office, including Dr. Peress, are devoted exclusively to your medical care. Please direct all matters relating to fees, billing, and insurance only to the business personnel.

PLEASE SIGN BELOW:

I understand I am responsible for the payment of all my services and agree to all of the above.
I hereby authorize the release of medical information to my insurance company and authorize payment of
benefits to Dr. Peress and/or Boca Fertility.

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