|
*Please download and print the following to obtain a full patient
packet
| Assisted Reproductive Technologies (ART) Booklet |
Download |
| Joint Notice of Privacy Practices |
Download |
| Authorization Form To Release Protected Health Information
(PHI) To Spouse / Significant Other and Acknowledgement Form
– Joint Notice of Privacy Practices: Patient and partner
will need to fill out and sign their own copy. |
Download |
| Insurance Waiver and Financial Policy: Patient and partner
will need to fill out and sign their own copy. |
Download |
| Regional Access Network (RAN) Patient Information |
Download |
| Directions to SRM |
Link |
| Accommodations |
Download |
| Consent To In Vitro Fertilization (IVF) Treatment |
|
- State of Alaska only
- All other states
|
Download
Download |
| Consent To Cryopreserve Embryos And Decisions For Future Disposition
Of Cryopreserved Embryos |
|
- State of Alaska only
- All other states
|
Download
Download |
| IVF Global Regional Base Price (please contact a financial
counselor for up to date IVF prices) |
Link |
| Shared Risk Refund Information (please contact a financial
counselor if your are interested in applying for this program) |
Link |
| CapitalOne Healthcare Finance |
Link |
| |
|
If you have any questions, please feel free to contact the Regional
Access Network Coordinator:
Sarah Sullivan
Direct: (206) 301-5029
Toll Free: (877) 777-6002
Financial Counselors:
Toll Free: (877) 777-6002
Revised
November 19, 2007
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