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Medical Records Request Use Or Disclosure Authorization

Medical Records Request Use Or Disclosure Authorization

How many Providers records you have to obtained ?*
Patient's name*
Date of Birth*

MM slash DD slash YYYY
S.S.N.
Partner's name*
Date of Birth*

MM slash DD slash YYYY
S.S.N.
Pursuant to the health Insurence Portability and Accountability Act(HIPAA) I/We, Hereby Authorize the following Provider(s)
Physician's Name*
Tel*
Fax
Address*
*** It’s important that we have your doctor’s fax #, please call your doctor’s office for the fax #.
To disclose the following protected health information to
Coastal Fertility Medical Center
15500 Sand Canyon Ave., Suite 100, Irvine, California 92618
Tel: 949-726-0697 Fax: 949-726-0601
Email: [email protected]
Attention: Lupe Castaneda
- Medical History, including specific progess notcs regarding any problems that would impact my treatments progress or outcome.
- Results of relevant diagnostic or laboratory tests.
Other
This protected health information is being used by the practice for the purpose of preparation treatment at the Coastal Fertility Medical Center. This authorization shall be in force and effect for 1 year.
- I understand that, as set forth in the Practice’ s Privacy Notice, I have the right to revoke this authorization, in writing, at any time by sending written notification to: Coastal Fertility Medical Center, 15500 Sand Canyon, Suite 100, Irvine, California 92618, Attn: Privacy Officer
- I understand that a revocation is not effective to the extent that the Practice has relied on the use or disclosure of the protected health information.
- I understand that information used or disclosed pursuant to th is authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.
- I understand that the Practice will not condition my treatment on whether I provide authorization for the requested use or disclosure.
- I understand that I have the right to:
- Inspect or copy my protected health information to be used or disclosed as pennitted under federal law (or state law to the extent the state law provides greater access rights.)
- Refuse to sign this authorization.
Patient's signature*
Partner's signature*
Date(Patient)*

MM slash DD slash YYYY
Date(Partner)*

MM slash DD slash YYYY
Second Provider
Patient's name*
Date of Birth*

MM slash DD slash YYYY
S.S.N.
Partner's name*
Date of Birth*

MM slash DD slash YYYY
S.S.N.
Pursuant to the health Insurence Portability and Accountability Act(HIPAA) I/We, Hereby Authorize the following Provider(s)
Physician's Name*
Tel*
Fax
Address*
*** It’s important that we have your doctor’s fax #, please call your doctor’s office for the fax #.
To disclose the following protected health information to
Coastal Fertility Medical Center
15500 Sand Canyon Ave., Suite 100, Irvine, California 92618
Tel: 949-726-0697 Fax: 949-726-0601
Email: [email protected]
Attention: Lupe Castaneda
- Medical History, including specific progress notcs regarding any problcms that would impact my treatments progress or outcome.
- Results of relevant diagnostic or laboratory tests.
Other
This protected health information is being used by the practice for the purpose of preparation treatment at the Coastal Fertility Medical Center. This authorization shall be in force and effect for 1 year.
- I understand that, as set forth in the Practice’ s Privacy Notice, I have the right to revoke this authorization, in writing, at any time by sending written notification to: Coastal Fertility Medical Center, 15500 Sand Canyon, Suite 100, Irvine, California 92618, Attn: Privacy Officer
- I understand that a revocation is not effective to the extent that the Practice has relied on the use or disclosure of the protected health information.
- I understand that information used or disclosed pursuant to th is authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.
- I understand that the Practice will not condition my treatment on whether I provide authorization for the requested use or disclosure.
- I understand that I have the right to:
- Inspect or copy my protected health information to be used or disclosed as pennitted under federal law (or state law to the extent the state law provides greater access rights.)
- Refuse to sign this authorization.
Patient's signature*
Partner's signature*
Date(Patient)*

MM slash DD slash YYYY
Date(Partner)*

MM slash DD slash YYYY
Third Provider
Patient's name*
Date of Birth*

MM slash DD slash YYYY
S.S.N.
Partner's name*
Date of Birth*

MM slash DD slash YYYY
S.S.N.
Pursuant to the health Insurence Portability and Accountability Act(HIPAA) I/We, Hereby Authorize the following Provider(s)
Physician's Name*
Tel*
Fax
Address*
*** It’s important that we have your doctor’s fax #, please call your doctor’s office for the fax #.
To disclose the following protected health information to
Coastal Fertility Medical Center
15500 Sand Canyon Ave., Suite 100, Irvine, California 92618
Tel: 949-726-0697 Fax: 949-726-0601
Email: [email protected]
Attention: Lupe Castaneda
- Medical History, including specific progress notcs regarding any problcms that would impact my treatments progress or outcome.
- Results of relevant diagnostic or laboratory tests.
Other
This protected health information is being used by the practice for the purpose of preparation treatment at the Coastal Fertility Medical Center. This authorization shall be in force and effect for 1 year.
- I understand that, as set forth in the Practice’ s Privacy Notice, I have the right to revoke this authorization, in writing, at any time by sending written notification to: Coastal Fertility Medical Center, 15500 Sand Canyon, Suite 100, Irvine, California 92618, Attn: Privacy Officer
- I understand that a revocation is not effective to the extent that the Practice has relied on the use or disclosure of the protected health information.
- I understand that information used or disclosed pursuant to th is authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.
- I understand that the Practice will not condition my treatment on whether I provide authorization for the requested use or disclosure.
- I understand that I have the right to:
- Inspect or copy my protected health information to be used or disclosed as pennitted under federal law (or state law to the extent the state law provides greater access rights.)
- Refuse to sign this authorization.
Patient's signature*
Partner's signature*
Date(Patient)*

MM slash DD slash YYYY
Date(Partner)*

MM slash DD slash YYYY
Fourth Provider
Patient's name*
Date of Birth*

MM slash DD slash YYYY
S.S.N.
Partner's name*
Date of Birth*

MM slash DD slash YYYY
S.S.N.
Pursuant to the health Insurence Portability and Accountability Act(HIPAA) I/We, Hereby Authorize the following Provider(s)
Physician's Name*
Tel*
Fax
Address*
*** It’s important that we have your doctor’s fax #, please call your doctor’s office for the fax #.
To disclose the following protected health information to
Coastal Fertility Medical Center
15500 Sand Canyon Ave., Suite 100, Irvine, California 92618
Tel: 949-726-0697 Fax: 949-726-0601
Email: [email protected]
Attention: Lupe Castaneda
- Medical History, including specific progress notcs regarding any problcms that would impact my treatments progress or outcome.
- Results of relevant diagnostic or laboratory tests.
Other
This protected health information is being used by the practice for the purpose of preparation treatment at the Coastal Fertility Medical Center. This authorization shall be in force and effect for 1 year.
- I understand that, as set forth in the Practice’ s Privacy Notice, I have the right to revoke this authorization, in writing, at any time by sending written notification to: Coastal Fertility Medical Center, 15500 Sand Canyon, Suite 100, Irvine, California 92618, Attn: Privacy Officer
- I understand that a revocation is not effective to the extent that the Practice has relied on the use or disclosure of the protected health information.
- I understand that information used or disclosed pursuant to th is authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.
- I understand that the Practice will not condition my treatment on whether I provide authorization for the requested use or disclosure.
- I understand that I have the right to:
- Inspect or copy my protected health information to be used or disclosed as pennitted under federal law (or state law to the extent the state law provides greater access rights.)
- Refuse to sign this authorization.
Patient's signature*
Partner's signature*
Date(Patient)*

MM slash DD slash YYYY
Date(Partner)*

MM slash DD slash YYYY
Phone

This field is for validation purposes and should be left unchanged.

Halloween 2019

Each year, Coastal Fertility Medical Center’s staff hosts a fun get together for our former patients and their families. View more photos from our 28th annual Miracle Babies Halloween event!

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Coastal Fertility Medical Center
15500 Sand Canyon Avenue
Suite 100
Irvine, CA 92618
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LGBTQ+ friendly fertility clinic.

About
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Resources
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Please complete the form so we can best serve and help you with your journey towards parenthood.

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Financial Transparency

Coastal Fertility Medical Center offers one of the most affordable fertility treatments and is completely transparent regarding the costs of procedures and any other expenses that you may have to pay before commencing your treatment. This differentiates us from some fertility clinics that reduce prices before the signing of the contract but charge you extra later on. We make sure our patients are well aware of any possible extra pricing that may occur over the course of their treatment.

CFMC Fertility Seminar Registration

On Demand Seminar Registration

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Embryo Transfer

Following the Preimplantation Genetic Screening process, which helps ensure there are normal chromosome numbers and detects possible genetic disorders, the most healthy embryo(s) are selected to be implanted into your or your chosen surrogate’s womb. 2 weeks after the transfer of the embryo, your physician will conduct a final blood test to determine the level of hCG (human chorionic gonadotropin) in your body. Increased hCG levels usually indicate a positive pregnancy test.

Fertilization

For fertilization to take place, the collected egg and sperm are combined in a petri dish and cultured in an embryo incubator. This dish is closely watched to check whether any of the eggs have been fertilized. Once the egg is fertilized, it is referred to as an embryo or a blastocyst on the 5th day of development. Our in-house embryologist carefully nurtures every embryo to the right time, even if it means working outside the standard business operating hours. For instance: If an oocyte is not mature, our laboratory will wait for it to mature and then ICSI it at the right time.

Egg Retrieval & Sperm Collection

The egg retrieval is a slightly invasive medical procedure that takes about 20 to 30 minutes. You will be given an anesthetic to make you sleep for the duration of the procedure. Using ultrasound technology, your doctor will harvest your eggs transvaginally with a small, hollow needle connected to an ultrasound probe. Once your eggs are collected, your partner’s semen or donor sperm you have pre-selected is used for fertilization. The sperm are washed and prepared, and the top-quality sperm extracted is used to fertilize the eggs.

Ovarian Stimulation

Your doctor will create a customized medication schedule that contains information about the fertility medications and hormone injections you have to take. Medication and injections are taken to encourage your ovaries to mature a large number of eggs for fertilization. Since women don’t respond to fertility drugs and hormones the same way, personalized protocols are crucial to the IVF cycle success. At Coastal Fertility, we will monitor you closely, letting you understand the changes occurring in your body and keeping track of how your egg follicles are growing.

Fertility Evaluation

On-site consultations typicallyinclude a standard fertility evaluation, consisting of a physical examination, complementary follicular ultrasound, and testing to enable your doctor to know your present fertility status and draw up a treatment plan.

Initial Consultation

This consultation includes a detailed medical evaluation with a doctor. You and your physician will review your health records and have enough time to talk about your goals and get answers to your questions. We recommend that you jot down all your questions before the visit to allow you to make the best use of the time spent with your doctor.

Plan of Care Creation

Your Reproductive Endocrinologist will take all factors into consideration and create a comprehensive plan of care, otherwise known as the treatment plan. This plan will include treatment recommendations from the physician and enable your financial coordinator to make a precise quotation once you meet.

Superior Expertise

Our globally respected team of specialists are helping improve IVF technologies to enter into a generation of better outcomes for infertility. Although you’ll have a doctor guiding you, you are also going to benefit from the experience and insights of other doctors during case review collaboration meetings, which take place every week. So, you won’t just rely on the expertise of a specialist but benefit from the knowledge of many reputed fertility experts.

A One-stop Model

The infertility industry is currently segmented, with each service or treatment being handled by a different provider. Our all-inclusive model simplifies an otherwise complex and difficult process. We are here to revolutionize the infertility industry by offering a one-stop-service model to assist our patients through infertility challenges while reducing physical, emotional, and financial risks.

LGBT friendly

Our fertility clinic focuses on helping you build your family regardless of your sexual orientation or the gender you choose to identify with. We are even taking further steps to make LGTB people feel more welcome at our fertility clinic. Each of our patient-facing staff goes through LGTB training to let family-building clinicians provide necessary support and make you feel highly welcome.

Personalized Solutions

We know that every situation is different and that everyone requires different treatments. Unlike facilities that take “a one-size-fits-all” approach for all cases, our fertility specialists use more than 40 customized protocols to raise the chances of success. The customized approach even extends to our fertility laboratory. Our on-site lab director and his highly-experienced team nurture every embryo and egg to increase the odds of success of each cycle.

Specialized in Difficult Cases

Our team specializes in difficult cases and help patients who may have been considered “hopeless” at other fertility clinics. Thanks to our personalized solutions, expertise, and internal collaboration, weare able to maximize pregnancy success rates that are well above the industry average, even in difficult infertility cases.

Welcome

Upon your arrival, you will check in with a Patient Care Coordinator. We will obtain your insurance information for benefits verification, a copy of your identification and take a picture for your electronic medical chart