Patient Paperwork
To best assist you and make your visit as productive as possible, please complete the following forms before your visit:
Or download individual forms below:
- Patient Information Form
- Patient Insurance Information Form
- Eligibility Guarantee Form
- Assignment of Benefits, Authorization & Financial Statement
- Open Payments Database Notice
- HIPAA Privacy Rule Individual Consent Agreement
- Comprehensive History Form
- Financial Policy (please review and initial each item)
- Patient Rights and Responsibilities
- Notice of Privacy Practices
- Medical Records Release Form
NOTE – Make sure to bring all medical records, hysterosalpingogram (HSG) films, operative reports, and clinic notes prior to your visit. Although not required, it is highly recommended that both partners be present at the initial consultation (if applicable). Please feel free to list your questions/concerns as you read our materials, and we will be happy to discuss them with you on your visit to FSAC. As a courtesy to patients on our waiting list, we ask you to inform us at least one week prior to your appointment if you are unable to attend.
We look forward to meeting with you. Please do not hesitate to contact our office with questions.