Fillable Infertility Program Patient Registration Form (Aetna Health Insurance)

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Infertility Program Patient Registration Form (Aetna Health Insurance)

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The Infertility Program Patient Registration Form (Aetna Health Insurance) form is 5 pages long and contains:

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  • 58 check-boxes
  • 98 other fields

Country of origin: US
File type: PDF

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Page 1 of 9
Infertility Program
Patient Registration Form
Applies to:
Aetna plans
Innovation Health® plans
Health benefits and health insurance plans offered and/or underwritten
by the following:
Allina Health and Aetna Health Insurance Company (Allina Health | Aetna)
Banner Health and Aetna Health Insurance Company and/or Banner Health and
Aetna Health Plan Inc. (Banner | Aetna)
Sutter Health and Aetna Administrative Services LLC (Sutter Health | Aetna)
Texas Health + Aetna Health Plan Inc. and Texas Health + Aetna Health Insurance
Company (Texas Health Aetna)
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including
Aetna Life Insurance Company and its affiliates (Aetna). Aetna provides certain management services on behalf of its affiliates.
GR-69058 (1-20)
GR-69058 (1-20) Page 2 of 9
Infertility Program
Patient Registration Form
About this form
This form will help us determine the infertility benefits and services you're eligible for under your plan.
How to complete this form
Fill out the entire form. Make sure to print clearly and sign it at the bottom.
When you’re done
You can fax your completed form to us at 1-860-607-7476. Or you can give it to your infertility provider to fax to us.
Questions?
If you have general questions about your plan coverage or benefits, call the number on the back of your Aetna
member ID card. You can speak to someone 8 a.m. to 8 p.m., 7 days a week.
If you need help with Questions 1 – 12 on the form, give us a call at 1-800-575-5999 (TTY: 711). We’re here 8 a.m. to
5 p.m. ET, Monday through Friday.
Please refer to our Infertility website at www.aetnainfertilitycare.com for important FAQ information which includes
details about our Institutes of Excellence Network for Infertility.
What happens next?
We’ll look over your form once we receive it. Then we'll contact your infertility provider. We’ll let them know if you
meet the initial criteria to start using your infertility treatment benefits.
We respect your privacy
We take the confidentiality of your personal health information very seriously. Your information is kept completely
confidential in compliance with the Health Insurance Portability and Accountability Act’s (HIPAA’s) privacy
regulations. We share your information only as permitted or required by law.
Also, in compliance with federal law, we won't ask you for any genetic information or your family medical history.
You don't have to provide any genetic information or family medical history to participate in our Infertility Program
unless you're requesting Preimplantation Genetic Diagnosis (PGD), which is the genetic testing of embryos created
in IVF. If you give us your genetic information or family medical history, you do so voluntarily.
GR-69058 (1-20) Page 3 of 9
Infertility Program
Patient Registration Form
/ / ( )
( ) ( )
Fill out your patient information.
Last name First name Middle initial
Birth date Home phone number
Work phone number Cell phone number
At what phone number can we reach you between 8 a.m. and 5 p.m.?
Home Work Cell Other:
Can we leave a detailed message if we get your voicemail?
Yes No
Do you consent to receiving text messages for any infertility precertification requests?
Yes No
What is your primary language? Do you requir
e hearing assistance?
Yes No
Mailing address
City
State ZIP code
E-mail address
Fill out your insurance information.
Aetna member ID number Group number
Name of insured
Do you have other insurance coverage?
Yes No
If “Yes,” provide the infor
mation below.
Name of insurance company Member ID number
Name of insured Reference number (if available):
GR-69058 (1-20) Page 4 of 9
Infertility Program
Patient Registration Form
Member ID: Reference Number (If available):
Write in your Infertility Provider’s Information.
Provider name Phone number
( )
Street address City, State, ZIP code
Answer thes
e questions as completely as possible.
Question 1: Are you trying to get pregnant right now?
Yes No If “No, please explain
Question 2: How have
you been trying to get pregnant?
Sexual intercourse
Artificial insemination with sperm from a known donor (for exampl
e, a spouse or partner)
Artificial insemination with sperm from an unknown donor (for example,
a sperm bank)
Question 3: Do you have a partner? Male Female
What is their full name?
Question 4: How long have you been trying to get pregnant?
Yea
rs: Months:
Question 5: Do you or your partner get regular periods
?
Yes No
If “No,” how often do y
ou get your period?
Question 6: After testing, did your doctor give you a reason why you’re having trouble getting pregnant?
Yes No
If “Yes,” what was the reaso
n?
Question 7: Have you or your partner ever had your fallopian tubes tied, cut, clipped, burned or blocked to prevent pregnancy?
Yes No
Question 8: Have you or your or partner had a vasectomy (a sterilization process) to prevent pregnancy?
Yes No If “Yes,” year he had the vas
ectomy:
Question 9: Have you or your or partner had a vasectomy reversed?
Yes No If “Yes,” year he had the vas
ectomy reversed:
Question 10: Have you ever had an infertility treatment, using medications or procedures, that didn’t result in pregnancy?
Yes No
If “Yes,” describe the treatment you had and dates of treatment:
Question 11: What infertility treatment h
as your doctor recommended for your treatment?
Intrauterine insemination (IUI) Donor egg IVF Fertility preservation IVF cycle
Donor insemination cycle (IUI) Frozen embryo transfer Invitro fertilization (IVF)
Pre-implantation genetic diagnosis (PGD)
Infertility Program
Patient Registration Form
Member ID: Reference Number (If available):
Tell us about your pregnancy history.
Month and year
of pregnancy
Infertility
therapy needed
to conceive?
Type of infertility treatment (Oral drugs;
injectable drugs; IUI; fresh IVF cycle;
donor egg or embryo cycle; or frozen
embryo transfer cycle)
Outcome
(Miscarriage;
ectopic; live birth;
or still birth)
Gestational age
at end of
pregnancy (for
example, full
term or 36
weeks)
/ Yes No
/ Yes No
/ Yes No
/ Yes No
/ Yes No
/ Yes No
/ Yes No
/ Yes No
/ Yes No
/ Yes No
Sign the form.
Your signature Today’s date
/ /
GR-69058 (1-20) Page 5 of 9
Type of infertility treatment (Oral drugs; injectable drugs; IUI; fresh IVF cycle; donor egg or embryo cycle; or frozen embryo transfer cycle)
Type of infertility treatment (Oral drugs; injectable drugs; IUI; fresh IVF cycle; donor egg or embryo cycle; or frozen embryo transfer cycle)
click to sign
signature
click to edit
Aetna complies with applicable Federal civil rights laws and does not unlawfully
discriminate, exclude or treat people differently based on their race, color, national origin,
sex, age, or disability.
Aetna provides free aids/services to people with disabilities and to people who need
language assistance.
If you need a qualified interpreter, written information in other formats, translation or other
services, call the number on your ID card.
If you believe we have failed to provide these services or otherwise discriminated based on
a protected class noted above, you can also file a grievance with the Civil Rights
Coordinator by contacting:
Civil Rights Coordinator,
P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA
93779),
1-800-64
8-7817, TTY: 711,
Fax: 859-425-3379 (CA HMO customers: 860-262-7705), CRCoordinator@aetna.com.
You can also file a civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human
Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC
20201, or at 1-800-368-1019, 800-537-7697 (TDD).
Aetna is the brand name used for products and services provided by one or more of the
Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry
Health Care plans and their affiliates (Aetna).
GR-69058 (1-20) Page 6 of 9
TTY:711
English To access language services at no cost to you, call the number on your ID card.
Albanian
Për shërbime përkthimi falas për ju, telefononi në numrin që gjendet në kartën tuaj të
identitetit.
Amharic
የቋንቋ አገልግሎቶችን ያለክፍያ ለማግኘት፣ በመታወቂያዎት ላይ ያለውን ቁጥር ይደውሉ
Arabic 
Armenian
Ձեր նախընտրած լեզվով ավվճար խորհրդատվություն ստանալու համար
զանգահարեք ձեր բժշ
կական ապահովագրության քարտի վրա նշված
հէրախոսահամարով
Bantu-Kirundi
Kugira uronke serivisi z'indimi ata kiguzi, hamagara inomero iri ku karangamuntu kawe
Bengali
Burmese
Catalan
Per accedir a serveis lingüístics sense cap cost per a vostè, telefoni al número indicat a la
seva targeta d’identificació.
Cebuano
Aron maakses ang mga serbisyo sa lengguwahe nga wala kay bayran, tawagi ang numero
nga anaa sa imong kard sa ID.
Chamorro
Para un hago' i setbision lengguåhi ni dibåtde para hågu, ågang i numiru gi iyo-mu kard
aidentifikasion.
Cherokee
ᏩᎩᏍᏗ ᎦᏬᏂᎯᏍᏗ
ᎢᏅᎾᏓᏛᏁᏗ Ꮭ ᎪᎱᏍᏗ ᏗᏣᎬᏩᎳᏁᏗ ᏱᎩ, ᏫᎨᎯᏏᎳᏛᏏ ᎾᏍᎩ ᏗᏎᏍᏗ
ᏥᏕᎪᏪᎵ ᎤᎾᎢ ID ᏆᏂᏲᏍᏗ ᏣᏤᎵ
Ꭲ.
Chinese Traditional 如欲使用免費語言服務，請撥打您健康保險卡上所列的電話號碼
Choctaw
Anumpa tosholi i toksvli ya peh pilla ho ish i payahinla kvt chi holisso kallo iskitini holhtena
takanli ma i payah
Chuukese
Ren omw kopwe angei aninisin eman chon awewei (ese kamé), kopwe kééri ewe nampa
mei mak won noum ena katen ID
Cushitic-Oromo
Tajaajiiloota afaanii gatii bilisaa ati argaachuu
f,lakkoofsa fuula waraaqaa eenyummaa (ID)
kee irraa jiruun bilbili.
Dutch
Voor gratis taaldiensten, bel h
et nummer op uw ziekteverzekeringskaart.
French
Pour accéder gratuitement aux services linguistiques, veuillez composer le numéro
indiqué sur votre carte d'assurance santé.
French Creole
(Haitian)
Pou ou jwen
n sèvis gratis nan lang ou, rele nimewo telefòn ki sou kat idantifikasyon
asirans sante ou.
German
Um auf den für Sie kostenlosen Sprachservice auf Deutsch zuzug
reifen, rufen Sie die
Nummer auf Ihrer ID-Karte an.
Greek
Για πρόσβαση στις υπηρεσίες γλώσσα
ς χωρίς χρέωση, καλέστε τον αριθμό στην κάρτα
ασφάλισής σας.
Gujarati
Hawaiian
No ka walaʻau ʻana me ka lawelawe ʻōlelo e kahea aku i ka helu kelepona ma kāu kāleka
ID. Kāki ʻole ʻia kēia kōkua nei.
Hindi
Hmong
Yuav kom tau kev pab txhais lus tsis muaj nqi them rau koj, hu tus naj npawb ntawm koj
daim npav ID.
GR-69058 (1-20) Page 7 of 9
Igbo
Inweta enyemaka asụsụ na akwughi ụgwọ obụla, kpọọ nọmba nọ na kaadi njirimara gị
Ilocano
Tapno maakses dagiti serbisio ti pagsasao nga awanan ti bayadna, awagan ti numero nga
adda ayan ti ID kardmo.
Indonesian
Untuk mengakses layanan bahasa tanpa dikenakan biaya, silakan hubungi nomor telepon
di kartu asur
ansi Anda.
Italian
Per accedere
ai servizi linguistici senza alcun costo per lei, chiami il numero sulla tessera
identificativa.
Japanese
無料の言語サービス
は、 IDカードにある番号にお電話ください。
Karen
Korean
무료 다국어 서비스를 이용하려면 보험 ID 카드에 수록된 번호로 전화해 주십시오 .
Kru-Bassa
I nyuu kosna mahola ni language services ngui nsaa wogui wo, sebel i nsinga i ye ntilga i
kat yong matibla
Kurdish
 ID  

Lao
Marathi
Marshallese
Micronesian-
Ponapean
Pwehn alehdi sawas en lokaia kan ni sohte pweipwei, koahlih nempe nan amhw doaropwe
en ID.
Mon-Khmer,
Cambodian
Navajo
Nepali
Nilotic-Dinka
Norwegian
For tilgang til kostnadsfri språktjenester, ring nummeret på ID-kortet ditt.
Pennsylvanian-
Dutch
Um Schprooch Services zu griege mitaus Koscht, ruff die Nummer uff dei ID Kaart.
Persian Farsi 
Polish
Aby uzyskać dostęp do bezpłatnych usług językowych, należy zadzwonić pod numer
podany na karcie identyfikacyjnej.
Portuguese
Para aced
er aos serviços linguísticos gratuitamente, ligue para o número indicado no seu
cartão de identificação.
Punjabi
Romanian
Pentru a accesa gratuit serviciile de limbă, apelați numărul de pe cardul de membru.
Russian
Для того чтобы бесплатно получить помощь переводчика, позвоните по телефону,
приведенному на ваше
й идентификационной карте.
Samoan
Mō le mauaina o 'au'aunaga tau gagana e aunoa ma se totogi, vala'au le numera i luga o
lau pepa ID.
Serbo-Croatian
Za besplatne prevodil
ačke usluge pozovite broj naveden na Vašoj identifikacionoj kartici.
GR-69058 (1-20) Page 8 of 9
Spanish
Para acceder a los servicios lingüísticos sin costo alguno, llame al número que figura en su
tarjeta de identificación.
Sudanic Fulfulde
Heeɓa a naasta nder ekkitol jaangirde woldeji walla yoɓugo, ewnu lamba je ɗon windi ha
do ɗerowol maaɗa.
Swahili
Kupata huduma za lugha bila malipo kwako, piga nambari iliyo kwenye kadi yako ya
kitambulisho.
Sy
riac-Assyrian
Swahili
Kupata huduma za lugha bila malipo kwako, piga nambari iliyo kwenye kadi yako ya
kitambulisho.
Tagalog
Upang ma-access ang mga serbisyo sa wika nang walang bayad, tawagan ang numero sa
iyong ID card.
Telugu
Thai
Tongan
Kapau ‘oku ke fiema’u ta’etōtōngi ‘a e ngaahi sēvesi kotoa pē he ngaahi lea kotoa, telefoni
ki he fika ‘oku hā atu ‘i ho’o ID kaati.
Turkish
Dil hizmetlerine ücretsiz olarak erişmek için kimlik kartınızdaki numarayı arayın.
Ukrainian
Щоб безкоштовнj отримати мовні послуги, задзвоніть за номером, вказаним на
вашій ідентифікайній картці.
Urdu
ُ
۔ﮟﯾﺮﮐ ﻝﺎﮐ ﺮﭘ ﺮﺒﻤﻧ ﺝﺭﺩ ﺮﭘ ڈﺭﺎﮐ ID ﮯﮐ ہﻤﻴﺑ ﮯﻨﭘﺍ ،ﮯﻴﻟ ﮯﮐ ﯽﺋﺎﺳﺭ ﺖﻔ ﻣ ﮏﺗ ﺕﺎﻣﺪﺧ ﯽﻧﺎﺴﻟ
Vietnamese
Để sử dụng các dịch vụ ngôn ngữ miễn phí, vui lòng gọi số điện thoại ghi trên thẻ ID của
quý vị.
Yiddish
.לטראק ID רעייא
ףיוא רעמונ םעד טפור ,לאצפא ןופ יירפ סעסיוורעס ךארפש ןעמוקאב וצ
Yoruba
GR-69058 (1-20) Page 9 of 9
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