New Patient Packet

Please note all information is confidential and will only be used for the purpose of ensureing you the best treatment possible. Please answer all areas.

Note: In order to help us more efficiently treat you, please obtain copies of your past fertility treatments, operative reports, IVF cycle, ultrasound reports, labs, and hard copies (films or on disk) of any

It is important that we review the HSG films that were previously done. Please bring these records to your appointment with you.

The goal of our practice is to make sure that you receive optimal care and attention to improve your chances of having a healthy pregnancy, and of course, a healthy child. An important part of family planning is being informed about your testing options. One of these options is genetic carrier screening. Carrier screening can help you understand your risk of having a child with a genetic disease.

Typically carriers are healthy individuals; but when two parents are carriers of the same genetic disease they can have a child affected with the disease. Most people do not know they are carriers until they have a child born with the disease.

The Universal Genetic Test screens for diseases such as Cystic Fibrosis, Tay-Sachs disease, and Sickle Cell disease. Some genetic diseases can significantly impair a child's normal development. For some of these conditions, early treatment can improve pregnancy outcomes. Your doctor can provide you with the full list of tested diseases.

If both you and your partner are carriers for the same disease, your child has a 1 in 4 (25%) chance of having that disease. If you are found to have a high reproductive risk, you have options. You may decide to have pre-implantation genetic diagnosis, a pre-pregnancy process that significantly reduces the risk that a child will inherit the genetic disease, or undergo testing during your pregnancy to make informed reproductive decisions. Some individuals consider adoption or opt to not have children. Even if you would not choose any of these options, you can use the information to prepare for the birth of a child with a genetic disorder. You will have the opportunity to speak with your physician or a genetic counselor about the medical options available to you.

Like any carrier screening test, some carriers will not be detected, so this test can reduce, but does not eliminate, the chance for a genetic disease.

The Universal Genetic Test is covered by most insurance policies. The test results will be sent to your doctor in about two weeks and you will be notified shortly thereafter.

Please take 3 minutes of your time to watch an online video and learn more: https://www.counsyl.com/howto/intro/

Please sign this form acknowledging that you and your partner will be screened.

Thank you for choosing Marin Fertility Center for your healthcare needs. Our staff is committed to providing you with extraordinary healthcare. This policy statement and release has been designed to inform you of our policies and answer your questions regarding payment of services. We encourage you to discuss it with us and to ask questions.

• You must pay any co-payment at the time of service
• If you have an insurance plan with an unmet deductible at the time of your office visit, you will be expected to provide an estimated payment or furnish a credit card authorization prior to services being rendered; there are no exceptions to this.
• The remainder of your bill will be sent to your health plan for direct payment to our office.
• If you are not insured, or if the services being provided are not covered by your insurance, you will be expected to provide payment in full for our services at the time they are rendered. One exception to this: for IVF treatment, payment must be received in full prior to the prescribing of your medication.
• In those instances where we have a participating provider agreement with your insurance company for an agreed upon negotiated rate for our services, an adjustment will be made in the amount of the difference between this rate and our normal fees at the time we receive payment from your insurance company. You will remain responsible for required copayments, applicable deductible amounts and any services that are not covered by your insurance plan.
• If, by mistake, your health plan remits payment to you, please send it to us along with all paperwork sent to you at the time.
• Your health plan may refuse payment of a claim for such reasons as:
  1. This is a pre-existing illness that is not covered by your plan
  2. You have not met your full calendar year deductible
  3. The type of medical service required is not covered by your plan
  4. The health plan was not in effect at the time of service
  5. You have other insurance which must be filed first
• We will bill your insurance up to two times. If payment is not made within 60 days of the second billing, you will be expected to make cash payment in full for any services that have been rendered and have not been paid by insurance.
• All bills from our office will be submitted to you electronically via your email (please let us know if you prefer to receive paper bills)

Please understand that financial responsibility for medical services rests between you and your health plan. While we are pleased to be of service by filing your medical insurance for you, we are not responsible for any limitations in coverage that may be included in your plan. If your health plan denies this claim for any of these or other reasons, our office cannot be responsible for this bill. It is your responsibility as patient to pay the denied amounts in full.

Our primary mission is to provide you with quality, cost effective, medical care. Together we are trying to adapt to the changing way that health care is financed and delivered. Again, we value you as a patient and our first priority is to provide you with the best possible care. I have read and understand my obligations and I acknowledge that I am fully responsible for payment of any services not covered or approved by my insurance carrier.

Article 1: Agreement to Arbitrate: It is understood that any dispute as to any medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompletely rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of a or relate to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim . In the case of any pregnant mother, the term "patient" herein shall mean both the mother and the mother's expected child or children.

All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician's partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician or patient to collect or contest any medical fee shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any malpractice claim, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party's pro rate share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party's own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law.

Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.

The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.

The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement , including, but not limited to, Code of Civil Procedure Sections 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any part may bring before the arbitrators a motion for summary judgement or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section 1283.05; however depositions may be taken without prior approval of the neutral arbitrator.

Article 4: General Provisions: All claims based on the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.

Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:

If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.