Permission to Verify Insurance

Permission to Contact Insurance Carrier and Agreement of Financial Responsibility
AUTHORIZATION FOR COASTAL FERTILITY MEDICAL CENTER / REPRODUCTIVE SPECIALTY LABS TO CONTACT MY INSURANCE CARRIER
I authorize Coastal Fertility Medical Center/Reproductive Specialty Labs to inquire on my behalf, regarding information about my benefits and coverage. I also authorize the release of any medical or other information necessary to process my insurance claim(s)
Patient signature*
Partner's signature*
Date(Patient)*

MM slash DD slash YYYY
Date(Partner)*

MM slash DD slash YYYY
AGREEMENT OF FINANCIAL RESPONSIBILITY and AUTHORIZATION TO BILL DESIGNATED INSURANCE CARRIER(S)
I authorize Coastal Fertility Medical Center (CFMC) / Reproductive Specialty Labs (RSL) to bill my insurance carrier(s), and I also authorize benefits to be paid directly to CFMC and RSL. If my insurance carrier, for any reason, will not cover a particular treatment, medication, or procedure, either in full or part, I understand, and agree it is my responsibility to remit payment in full, unless prior written arrangements have been made with the CFMC/RSL billing department
Patient’s Signature*
Partner's signature*
Date(Patient)*

MM slash DD slash YYYY
Date(Partner)*

MM slash DD slash YYYY
**SIGN BELOW ONLY IF YOU DO NOT WANT US TO CONTACT YOUR INSURANCE CARRIER**
DO NOT CONTACT INSURANCE CARRIER
I wish to be a cash account. PLEASE DO NOT CONTACT MY INSURANCE CARRIER FOR ANY REASON, unless I request (in writing) for you to do so.
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!

Tour Our Irvine, CA Fertility Center

Take a virtual tour of our extraordinary fertility clinic located in Southern California. Our state-of-the-art factility spans 10,000 square feet, and offers patients the latest in fertility technology.