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Download Forms

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

     

     

     

    These forms are required when visiting Henry Fertility for the first time in order to create your patient chart.  Please bring all forms completed to your first appointment along with your insurance card, if applicable, and photo I.D.

     

  • New Insurance Information

    Please print out and complete this form if there have been changes or updates to your insurance policy.  Send a copy of the front and back of the new card along with this completed form via email or bring it to your next appointment.  New information can be emailed to:  info@henryfertility.com

     

  • Change in Patient Information

    Please print and complete a new patient registration form if you have a new address, or if your last name has changed.  Bring the completed form to your next appointment along with a photo i.d.

  • Release of Records

    Please complete this form and return it to our office in order to start the process of having medical records released.

     

  • 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

     

     

     

    This form is for Physicians and/or medical professionals to refer a patient to Henry Fertility for treatment.  Please fax this form along with any pertinent medical records.

     

201 Pennsylvania Parkway,

Suite 325

Indianapolis, IN 46280

 

3920 East St. Francis Way

Suite 219

Lafayette, IN 47905

 

 

1429 North 6th Street

2nd Floor

Terre Haute, IN 47807

 

 

 

2920 McIntire Drive,

Suite 250

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