New Patient Information Sheet

NEW PATIENT INFORMATION SHEET

Thank you for your interest in Columbia Fertility Associates. Your appointment with Dr. has been scheduled for _ at . We have Financial Counselors on staff that will work closely with you to help you understand your insurance benefits or self pay responsibility. Please allow an additional 15 minutes to meet with your Financial Counselor after your consultation if needed.

PMleaseedica clo Imnfpolrmaete tihoen en: closed forms and bring them with you at the time of your visit. Please bring any previous medical records with you to your appointment.

YInosuuran arece req anudi redPaym toe nptay: all co-payments and deductibles at the time of service. If your insurance does not cover your office visit, we will ask for payment in full at the time of service. Charges for diagnostic and/or laboratory tests are N O T included in the office visit fee. Information on all fees is available. We accept cash, personal checks, Visa, MasterCard, Discover, and American Express.

Due to the specialized nature of our practice, our fees sometimes exceed the amount allowed by your insurance company. You are responsible for any balance that may accrue. We ask that you be familiar with your particular health plan and coverage.

Many insurance companies will honor an assignment of benefits and make payments directly to your physician. If you are covered by one of these plans, as a courtesy to you, our billing department can submit your claim. You will still be responsible for any services not covered by your insurance plan. If your outstanding balance is assigned to a collection agency, you will be responsible for all reasonable recovery costs including attorney’s fees.

C FA w i l l c harg e a $50.00 f e e f or a n y a ppo i n t m e nt c a n c elle d or b r oken wi t ho u t 2 4 ho ur s a d va nced no ti ce. W e a l so c harg e a $ 5 0.00 f e e f or a l l r e t u r n e d c h e cks.

I have read and agree to the above policies:

Signature Date

www. C o l u m b i a F e r t ili t y A s s o ci a te s .c o m

2440 M St., NW, #401 10215 Fernwood Rd., #301A 1005 N. Glebe RD #470 Washington, DC 20037 Bethesda, MD 20817 Arlington, VA 22201 (202) 293-6567 (301) 897-8850 (703) 525-4776

2440 M St. NW, Suite 401, Washington, DC 20037. The phone number is 202- 293-6567. The main entrance of the building is on the corner of 25th and M Streets, a five minute walk from the Foggy Bottom Metro Stop. There is metered parking on the streets and a parking garage under the building. The entrance to the parking garage is on M Street, between 24th and 25th Streets. We d o no t v a li d a t e p ark i n g .