Get For Financial Responsibility And

Filling out the For Financial Responsibility And form is an important step in your journey towards treatment. This guide provides clear and supportive instructions on how to effectively complete this document online, ensuring you are well-prepared for your upcoming procedure.

Follow the steps to successfully fill out the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by reviewing the sections of the form. Identify your role by circling the corresponding option such as Anonymous Recipient, Intended Parent, Gestational Carrier, Known Donor, or Known Recipient.
3. Enter the estimated dates by checking the relevant boxes for Retrieval Date, Transfer Date, or FET Date. Fill in your selected physician’s name by circling the appropriate option or writing 'Other' if applicable.
4. In the Patient Information section, clearly print your name (last, first, MI), social security number, home address, date of birth, and contact details, including home and cell phone numbers.
5. Provide your marital status, age, occupation, and employer's name and address in the specified fields.
6. Fill out the information for the person responsible for the hospital bill, including their name, address, date of birth, and social security number. Indicate their relationship to you and provide their contact information.
7. If IVF is covered by your insurance, complete the Insurance Information section. Provide the primary and secondary insurance company details, including the subscriber's name, employer, and policy numbers. Attach a copy of the front and back of your insurance card.
8. You may need to include the necessary claims phone numbers and pre-certification phone numbers for both primary and secondary insurances.
9. Review all information for accuracy. Once you have completed the form, save your changes. You can then download, print, or share the completed form as needed.

Complete your forms online to ensure a smooth process for your treatment.