For your convenience, new patient medical forms, insurance information and questionnaires are provided below. Completing this information prior to your appointment will facilitate the process of data gathering by the physician. It will also allow you and your partner to have your questions answered adequately and in person.
The down-loadable forms are .pdf files and will require Adobe Acrobat 10 to view and complete. To download a free version of Adobe Acrobat 10, please click the link.
If you have questions regarding which forms are required for your specific needs, please feel free to contact our office.
Once downloaded, you may:
- Print the forms and fill them out by hand (Fax them to our office 317-817-1810 or bring them in person).
- Fill them out on your computer using Adobe Acrobat, print them, sign and date the appropriate signature lines. (Fax them to our office 317-817-1810 or bring them in person).
New Patient Forms
New Insurance Information
Change in Patient Information
Release of Records
Outside Monitoring Patient Forms
If you are scheduled to be monitored in our office as ordered by an offsite physician or agency, please print and out and bring the completed registration forms to your first appointment. You will be required to bring a copy of the order from the physician to each appointment. This means if you are scheduled for multiple monitoring appointments, you will be required to bring a copy of each individual order to each appointment. Monitoring appointments are at 8:30am on your scheduled appointment day.
Outside Monitoring Order Forms
The following monitoring request form and physician order form are required to be completed and faxed to our office in order for any outside monitoring patient to be scheduled, patients must have a scheduled time. We do not accept walk ins. Once the order has been received with the required dates, the patient will be put on the schedule.
Physician Referral Form
201 Pennsylvania Parkway,
Indianapolis, IN 46280
3920 East St. Francis Way
Lafayette, IN 47905
1429 North 6th Street
Terre Haute, IN 47807
2920 McIntire Drive,
Bloomington IN, 47403
At Reproductive Care of Indiana, we are committed to respecting your privacy. Any information we obtain about you via this website
will only be used as described in our “Notice of Privacy Practices for Protected Health Information.”
© 2019 Reproductive Care of Indiana All Rights Reserved.
1010 West 2nd Street
Bloomington, In 47403