Microsoft word - mcrh patient website forms 04-13.doc

THE MIDWEST CENTER FOR
REPRODUCTIVE HEALTH, P.A.
AND THE SUBSIDIARIES MCRH ALPHA, P.A.
AND GREAT PLANES RE
PRODUCTIVE
Phone 763.494.7700
CENTERS, P.A.
Toll Free 800.508.9763
Fax 763.494.7706
Web Site www.mcrh.com
Patient Guide
The Midwest Center for Reproductive Health, P.A.

Thank you for choosing The Midwest Center for Reproductive Health, P.A. (MCRH). Please accept our
warmest welcome to you from the staff at MCRH, as well as our thanks for your interest in the services we
provide. We understand the struggles that you face and truly strive to provide the finest care possible in a
compassionate and professional environment. It is our hope that we will lay the foundation for success with
our individualized treatment based on the unique needs of each patient. We ask that you use this information
as a guide in order to familiarize you with MCRH and prepare yourself for what to expect before, during, and
beyond your first appointment.
Before Your Appointment:
To ensure your new patient appointment is most beneficial to you, we begin by asking that the following forms
be thoughtfully completed and received in our office one week before your appointment. Please feel free to
return your completed forms by mail or fax to (763) 494-7706. If you choose to fax your completed forms,
please bring the original copy to your scheduled appointment. If you have a copy of your medical records, you
may include a copy with the following forms:

___ Patient Registration Form and Consent for Treatment – Carefully read and complete both pages of
this form. Since this serves as a consent for services, completion of this form is required before your appointment. Be sure to have both patient and spouse or partner (if applicable) initial, sign, and date. ___ History Forms (both female and spouse/partner) – Each of you should individually complete the
appropriate form to the best of your knowledge. Please indicate “not applicable” when this is the case. Completion of these forms allows the staff at MCRH to better understand your individual situation and provide a more individualized discussion during your consultation.
____ Medical Records – It is most beneficial if medical records from current and/or previous infertility
treatment are received in our office before your consultation. In order to expedite the transfer of your
previous medical records, enclosed is an “Authorization for Release of Medical Information” form for
you to return directly to your physician. If you and/or your partner have more than one physician that
you have been working with, please feel free to duplicate or to ask MCRH for additional copies of this
form. Any medical records released from other facilities will have pertinent information extracted and will
be returned to you at the time of your new patient consultation. If your new patient consultation is done
via phone, the records will be mailed back to you.
____ Preparing for Pregnancy – Please read this guide for information to best optimize your chances for
You should also expect a telephone call from one of the MCRH nursing staff before your appointment. The nurse will confirm your appointment, the receipt of your new patient paperwork and your medical records, and will ask any questions regarding your medical history. This phone conversation will help further to clarify your individual situation and any specific topics you wish to discuss during your initial consultation.
What to Expect at Your New Patient Appointment:
Your initial appointment is scheduled as a consultation with Dr. Corfman. In order to give you both the
opportunity to meet him and other members of the MCRH team, we strongly recommend both you and your
spouse or partner attend the new patient consultation. During this appointment you will have the opportunity to
have a dialogue between you and Dr. Corfman, review any previous treatments, and discuss options for further
treatment. Generally, this appointment is approximately 30 minutes in length however, please keep in mind
that your appointment may be longer or shorter depending on your unique requirements. It is with sensitivity
to all patients and with regards to the particular nature of our practice, we ask that children do not
accompany you to your appointment.
Office
Location:
Our office is located in Maple Grove, MN. Please see the map on our website for specific location. There are also many additional satellite locations in other areas as well. Please see the Practice Locations page for alternate locations. If you have any questions regarding directions, please call the front desk at: (763) 494-7700 or (800) 508-9763 and select option 1. Cancellation Policy:
A fee will apply for appointments not cancelled at least 72 hours in advance. While we regret the need to
do this, this policy allows us to better serve all of our patients who may be waiting for an appointment
time.
Billing and Insurance Policies and Questions:
Understanding your medical insurance coverage and your benefits for infertility treatment can be
confusing and time consuming. Our Business Office staff is available to answer questions as they arise.
However, because plans vary greatly, it is probably best to start by contacting your insurance company
directly. Please see the Insurance and Financial Information on our website.
The fee for a new patient consultation is generally $370, although this can vary depending on the amount of time spent, the complexity of your medical history, and your options for treatment. This appointment may or may not be covered by insurance and includes chart preparation, extraction of your previous medical records, medical records review with a member of the nursing staff before your appointment, and your physician consultation. MCRH participates with a number of insurance plans, however, coverage caries. We ask you to contact your insurance company before your appointment. If we do not participate directly with your insurance, there may be “out of network” benefits allowing you to see Dr. Corfman. If you have questions or concerns regarding fees or insurance coverage, please contact the
Business Office by calling (763) 494-7736. Many times all it takes is a phone call to ease your
insurance concerns and answer your questions.
We look forward to meeting you at your new patient consultation.
Please do not hesitate to call with further questions.
Additional Helpful MCRH Information

Office Hours:
 Monday through Thursday, 7:00 a.m. - 4:00 p.m.
 Weekend/holiday hours are available by appointment. Appointment Scheduling:
Telephone hours are as follows:
 Monday through Thursday, 8:00 a.m. - 12:00 p.m., 1:00 p.m. - 4:00 p.m. Please feel free to call for appointments, medication refills, general questions, and other routine clinic communications during these times.
After clinic hours and weekends:
 Non-emergency calls should be made to the nurse line at (763) 494-7726. Messages may be left at
any time and if necessary, a nurse will return your call by the following day.  In case of an emergency, the answering service may be phoned at (763) 494-7700 or (800) 508-9763.
A nurse will be paged to return your call and medical direction will be given. Please note that in order to serve all of our patients, we ask that you only page the on-call nurse in an emergency. Non-emergent pages will be billed accordingly. Laboratory Services:
 Monitoring services and procedures that can be performed at MCRH include: ultrasounds, specific
blood testing, intrauterine insemination, post coital testing and sonohysterograms.  Laboratory services are coordinated between our office and affiliated laboratories.  Patients may also choose to coordinate specified laboratory procedures through the services affiliated Andrology Services:
 Andrology services include: semen analysis, semen analysis with strict criteria, antisperm antibody
testing, intrauterine insemination preparation, and cryopreservation of back up semen specimen.  Andrology services are available and conducted through our Reproductive Biology Laboratory by appointment. Testing will be done from 8:30 a.m. - 1:00 p.m. Monday through Thursday and 8:30 am - 10:00 am on Friday.
Support Services/Social Worker:
 Sally Sibbitt, MSW, LICSW, is a clinical social worker specializing in working with infertility and
reproductive loss, as well as with other issues. She is a valuable member of our team and we encourage you to utilize her services. She may be contacted directly by calling (952) 925-3533.
Medical Records Policy:
 If you would like to receive a copy of your medical records after becoming a patient of ours, please call
(763) 494-7700 or (800) 508-9763. An MCRH Authorization for Release of Medical Information and/or a current Patient Registration Form is required and must be signed by both patient and spouse/partner if applicable. As per MCRH policy, appropriate fees will apply. THE MIDWEST CENTER FOR
REPRODUCTIVE HEALTH, P.A.
AND THE SUBSIDIARIES MCRH AL
PHA, P.A.
AND GREAT PLANES RE
PRODUCTIVE
Phone 763.494.7700
CENTERS, P.A.
Toll Free 800.508.9763
Fax 763.494.7706
Web Site www.mcrh.com
Preparing for Pregnancy
While conception is as easy as "falling off a log" for some people, it is not so easy for many of us. We all know
couples who are unhealthy and choose unhealthy lifestyles, yet seem to have no trouble becoming pregnant.
Two of the most important lifestyle factors negatively impacting pregnancy and chances of becoming pregnant
are smoking and obesity. The medical literature is full of information which shows smoking (yes, even use of
chewing tobacco) and being overweight significantly decreases chances to conceive. Furthermore, both
smoking and being overweight have very serious negative effects upon you and your unborn baby, and on
your baby’s health after birth.
Just as the pilot of an airplane meticulously prepares and performs preflight planning, so, too, should you
prepare to become pregnant. When you ask our team at The Midwest Center for Reproductive Health to help
you launch and "get this baby off the ground," we recognize that you are also committing to do what is
necessary to optimize chances for success. We take your commitment very seriously, just as we take
seriously our commitment to help you achieve a pregnancy and a healthy baby.
For those of you who are significantly overweight, we want you to know that we do not wish to begin infertility
treatment until you are in a position to be successful. What defines being "significantly overweight"? The
National Institutes of Health has adopted a measurement which correlates height and weight with health risks,
termed the body mass index (BMI). Studies have shown a body mass index between 19 and 25 to be in a
healthy range, whereas a BMI of 30 or greater to be associated with significant health risks. To determine your
BMI please go to www.bmi-calculator.net or consult with your local health care provider.
Should your BMI be above 30, it is important for you to know that many studies have shown significant
negative impacts upon your chances to conceive, greatly increased chances of complications during your
pregnancy and increased chances for health problems in your baby. With this in mind, we discourage initiation
of infertility treatment until your BMI is 30 or under.
Having a BMI over 30 is not only a problem for women trying to conceive, but also for men. Sperm function is
significantly compromised with elevated BMI.
Should your BMI be 35 or greater, we ask that you seek care with your local health care provider and establish
a plan for reducing your BMI before you schedule an appointment with Dr. Corfman.
Should you be users of tobacco products, it is important for you to be tobacco and smoke-free before you
initiate infertility treatment. When you do your part to prepare for pregnancy, you put yourself in an excellent
position to be a parent of a healthy baby. We know that is your goal, and we will be there to help you when
you’re ready.
THE MIDWEST CENTER FOR REPRODUCTIVE HEALTH, P.A.
AND THE SUBSIDIARIES MCRH ALPHA, PA AND
GREAT PLANES REPRODUCTIVE CENTERS, P.A.
Full completion of this form is mandatory prior to providing any medical services.
PATIENT REGISTRATION RECORD/CONSENT FOR TREATMENT
Date ___________ Appt. Date ____________ Physician Referred: Yes____ No____ If yes, Name_____________________
FEMALE PATIENT INFORMATION (Print legal name as it appears on driver’s license, social security card, etc.)
Patient______________________________________________________________________________________________________ Address_______________________________________________ City_______________________________________________ State__________ Zip________________ Phone (_______) ___________-_____________ Birth Date _________-_________-_________ Social Security Number ___________-______-__________ Current Marital Status _________Married _________Divorced _________Single _________Widowed *Marital Status is required to provide necessary consenting and patient chart preparation. Email address: _________________________________________ Employer___________________________________ Phone (_______) __________-___________ Employer’s Address______________________________________ City______________________ State________ Zip___________ Patient’s Primary Insurance Company/Plan Name ___________________________________________________________________ Group # ______________________ Contract/ID#__________________________ Policy Holder Name________________________ Eff Date_______________________ Insurance Company Address______________________________________________________ *Please refer to the business office information in your new patient packet for specifics regarding insurance.
SPOUSE/PARTNER INFORMATION  Spouse  Partner (please check appropriate box)
(Print legal name as it appears on driver’s license, social security card, etc.) Spouse/Partner Name__________________________________________________________________________________________ Birth Date _________-_________-_________ Social Security Number ___________-______-__________ Employer___________________________________ Phone (_______) __________-___________ OK to Call Y / N Employer’s Address______________________________________ City______________________ State________ Zip___________ Insurance Company/Plan Name__________________________________________________________________________________ Group # ______________________ Contract/ID#__________________________ Policy Holder Name________________________ Eff Date_______________________ Insurance Company Address______________________________________________________ *Please refer to the business office information in your new patient packet for specifics regarding insurance. EMERGENCY CONTACT
Name of Person to Contact (not living with you)___________________________________________ Relationship_________________ Address__________________________________________________________________ Phone (______) _________-__________ THE MIDWEST CENTER FOR REPRODUCTIVE HEALTH, P.A. AND THE SUBSIDIARIES
MCRH ALPHA, PA AND GREAT PLANES REPRODUCTIVE CENTERS, P.A.
CONSENT FOR SERVICES
The following information must be initialed and signed by both patient and spouse/partner below. Please indicate if spouse/partner is
not applicable. Full completion of this form is mandatory prior to The Midwest Center for Reproductive Health, P.A (MCRH)
and its subsidiaries providing any medical services.

_____ _____ CONSENT
TREATMENT. I hereby consent to and authorize the physician(s) and their designees to perform
whatever routine diagnostic procedures, treatment, laboratory tests, and to administer such medications in his/her
_____ _____ TESTING.
I understand that while receiving care accidental exposure to my blood or other body fluid may occur. If this rare event occurs, I understand that my blood will be tested for the presence of Bloodborne Pathogens (Hepatitis B, Hepatitis C, and Human Immunodeficiency Virus). These tests are necessary to help protect and counsel the exposed individual. I understand that results of the tests will be a part of my medical record and will not be released except with my prior consent or as required or permitted by law.
_____ _____ MEANS
COMMUNICATING. I authorize the practice to disclose or provide protected health information about
Patient S/P Initial my/our treatment directly to me at the address, home phone, work phone and/or cell phone number that I/we have Initial indicated on my Patient Registration and Consent for Treatment form. I understand that it is my responsibility to notify the practice of any change in this manner of communication. I understand that the practice has no control regarding persons who may have access to the mailing address and listed numbers I have designated to receive my protected health information. Therefore, I understand that my protected health information disclosed will no longer be the responsibility of the practice.
_____ _____ RELEASE OF MEDICAL RECORDS. I hereby authorize MCRH to release to myself, spouse/partner, my referring
physician, insurance company, physicians referred by MCRH, or legal guardian, any information of treatment and diagnosis, concerning my past and present medical care. I understand that my medical records will be maintained jointly with my spouse/partner’s throughout my care at MCRH. Additionally, I authorize access to MCRH Reference Laboratory results if previously tested. I understand and accept the risks associated with releasing medical records via fax, mail, or in rare cases email with appropriate authorization. __ _____ NOTICE OF PRIVACY PRACTICES. I acknowledge the receipt the Notice of Privacy Practices effective April 08,

_____ _____ IDENTIFICATION. I understand MCRH requires validation to secure patient’s identity via picture ID at the time of new
Patient S/P Initial patient appointments to comply with HIPAA Privacy Practices. I understand MCRH requires my Social Security Initial Number to use as my unique identifier throughout my care.
_____ _____ RELEASE
PERSONAL PROPERTY RESPONSIBILITY. I understand that MCRH is not responsible for the loss
Patient S/P Initial of valuables and assumes no responsibility for any losses. Initial _____ _____ PAYMENT/INSURANCE
CONSENT. I acknowledge responsibility for payment for services rendered to me at
Patient S/P Initial MCRH. I understand it is my responsibility to obtain a referral from my primary care physician for all care received at Initial MCRH if my insurer requires it. Claims will be submitted under the company/facility name and not the
physician. I acknowledge and accept responsibility for all charges denied or identified as non-covered by my insurer.
If my account becomes delinquent, I agree to pay all costs the center may incur in collecting its fees including
collection agency & attorney fees. If charges on my account are not fully paid within 120 days of the date of service, I
also agree to pay interest from that date at a rate of 1.5% per month. Unless full payment is made on the date of
service, I authorize my insurer to pay my medical benefits directly to MCRH.

_____ _____ SATELLITE
PATIENTS:
I acknowledge that while being seen at any location other than Maple Grove, Dr. Corfman Patient S/P Initial may not be a provider in my insurance network at that facility. Billing will be through GPRC for visits at a satellite Initial location. Management fees, education and phone appointments will be billed through MCRH or MCRH Alpha. _____ _____ MAPLE
PATIENTS: MCRH Alpha is an “in network” provider for non-IVF treatment for Health Partners,
Patient S/P Initial Cigna, BCMN, Preferred One and TriCare. IVF Patients: IVF Treatment will be billed through MCRH, which is “in-
network” with Health Partners and HP/Cigna. Patient Legal Name Printed __________________________________________________________________________ Patient Signature ______________________________________________ Date ___________________________ Spouse/Partner Legal Name Printed __________________________________________________________________ Spouse/Partner Signature ________________________________________ Date ___________________________ THE MIDWEST CENTER FOR REPRODUCTIVE HEALTH, P.A.
Female History Form
Each of you should individually complete the appropriate form to the best of your knowledge.
I. IDENTIFYING INFORMATION

Name _____________________________________ Partner’s Name ____________________________________
Date of Birth _______________ Duration of Relationship ___________ Duration of attempting pregnancy_________
Nature of present employment (title, brief description) __________________________________________________
II. MEDICAL HISTORY
Do you have or have you ever been diagnosed with or treated for (check all that apply): ____ Hirsutism (excessive hair growth) ____ Endometriosis Antibiotics needed for dental/surgical procedure If yes, list: ______________________________________ If yes, list: ______________________________________ If yes, list: _______________________________________ If yes, list: _______________________________________ If yes, list: _______________________________________ If yes, list: _______________________________________ If yes, type: ____________ amount per week:___________ If yes, type: ____________ frequency:_________________ III. CONTRACEPTIVE/SEXUAL HISTORY
Have you used in the past (check all that apply): ____ Birth Control Pills Name: ___________________________ ____ IUD Name: __________________________ ____ Depo-Provera If you’ve ever been on oral contraceptives (pills), were your periods regular after stopping the pills? Is intercourse painful or difficult for you?
How many times per week do you and your partner have intercourse? ____________________________
How many times do you have intercourse at the time of ovulation? _______________________________
Indicate your sexual orientation by circling one of the following: Heterosexual Homosexual Bisexual Transgender
IV. MENSTRUAL AND PREGNANCY HISTORY

Age at first period? _______________
Are your periods regular?
If yes, what is the usual length (from onset of period to the onset of your next period) ? __________ If no, how many times per year do you menstruate? ____________ Progesterone or Provera needed to initiate bleeding? What is the usual duration of your flow? ________ Are cramps: How many pregnancies (including elective abortions) have you had? _____________ (choose one)
Elective Abortion?
Miscarriage?
Infertility
Ectopic?
Is current
Pre-term Delivery?
delivery
How long to
required to
Full-term Delivery?
Pregnancy
conceived
conceive?
conceive?
Stillborn?
section? Complications? female

V. FAMILY HISTORY
Is there a family history of cancer/malignancy Is there a history of hormonal disorders in your family? Yes If yes, who and what type ___________________________________________________ With which of the following racial/ethnic group do you identify? Check the appropriate racial/ethnic group? ___ American Indian/Alaska Native ___ Unknown/Not Stated
VI. INFERTILITY HISTORY/TREATMENT

Have you been treated for infertility before? Yes No
If yes, who was your physician? _____________________________________________ Infertility diagnosis? _______________________________________________________ Which of the following tests have you had performed? Check all that apply and list the results if known: ____ ____ Hormonal Testing (FSH,LH, prolactin, estrogen, DHEA-S, testosterone, progesterone) When?___________ Results:_______________________ When?___________ Results:_______________________ When?___________ Results:_______________________ Immunology/Recurrent Pregnancy Loss Testing (if applicable) Anticardiolipin When?___________ Results:_______________________ When?___________ Results:_______________________ Have you ever had any of the following procedures/surgeries: Appendectomy Indicate the following treatment types you have undergone or are currently undergoing: ______ Clomid ___ Donor Sperm Number of Cycles: ________ Facility/location where treatment occurred __________________________________________ THE MIDWEST CENTER FOR REPRODUCTIVE HEALTH, P.A.
Male History Form
Each of you should individually complete the appropriate form to the best of your knowledge.
I. IDENTIFYING INFORMATION
Name _____________________________________ Partner’s Name ____________________________________ Date of Birth _______________ Nature of present employment (title, brief description) _________________
II. MEDICAL HISTORY
Do you have or have you ever been diagnosed with or treated for (check all that apply): If yes, list: ______________________________________ If yes, list: ______________________________________ If yes, list: _______________________________________ If yes, list: _______________________________________ If yes, list: _______________________________________ If yes, list: _______________________________________ If yes, type: ____________ amount per week:___________ If yes, type: ____________ frequency:_________________
Do you frequently use saunas, steam baths, or whirpools?
Have you had a high fever (over 102° F) during the past three to four months? Have you ever tried to produce a child with another partner? Have you produced a child with another partner? If yes, how long did it take to produce the child? ________ Do you have trouble getting an erection? Do you have trouble maintaining an erection? Do you feel that your ejaculate is deposited Do you have any abnormal discharge from your penis? How many times per week do you and your partner have intercourse? __________ How many times do you have intercourse around ovulation? _____________ Have you recently noticed a change in your sexual drive? Have you had an injury or an abnormality of penis, testicles or prostate? Outcome/result _________________________ Indicate your sexual orientation by circling one of the following: Heterosexual Homosexual Bisexual Transgender Has your partner ever conceived a child with someone other than yourself?

IV. FAMILY HISTORY
Is there a history of hormonal disorders in your family? Yes If yes, who and what type _____________________________________________________ With which of the following racial/ethnic group do you identify? Check the appropriate racial/ethnic group: ___ American Indian/Alaska Native

V. INFERTILITY HISTORY/TREATMENT

Have you been treated for infertility
If yes, who was your physician? ____________________________________________ What cause of infertility was diagnosed? ____________________________________________ Is your partner currently seeing a doctor for evaluation of infertility? If yes, specify physician name and location _____________________________________ Which of the following tests have you had performed? Check all that apply and the results, if known: ____Semen Analysis When? ________ Results: ______________________ When? ________ Results: ______________________ When? ________ Results: ______________________ When? ________ Results: ______________________ When? ________ Results: ______________________ When? ________ Results: ______________________ When? ________ Results: ______________________ When? ________ Results: ______________________ When? ________ Results: ______________________ When? ________ Results: ______________________ When? ________ Results: ______________________ Have you every had any of the following procedures or surgeries: Hernia What drugs have you taken for infertility? Check all that apply: ___Clomiphene Citrate (Serophene, Clomid) THE MIDWEST CENTER FOR
REPRODUCTIVE HEALTH, P.A.
AND THE SUBSIDIARIES MCRH ALPHA, P.A.
AND GREAT PLANES REPRODUCTIVE
CENTERS, P.A.
Phone 763.494.7700
Toll Free 800.508.9763
Fax 763.494.7706
Web Site www.mcrh.com
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed, and how you can gain access to this
information. Please review it carefully.

Protected health information (PHI), about you, is maintained as a written and/or electronic record of your contacts or visits for
healthcare services with our practice. Specifically, PHI is information about you, including demographic information (i.e. name, address,
phone, etc.), that may identify you and relates to your past, present or future physical or mental health condition and related healthcare
services.
Our practice is required to follow specific rules on maintaining the confidentiality of your PHI, using your information, and disclosing or
sharing this information with other healthcare professionals involved in your care and treatment. This Notice describes your rights to
access and control your PHI. It also describes how we follow applicable rules and use and disclose your PHI to provide your treatment,
obtain payment for services you receive, manage our healthcare operations and for other purposes that are permitted or required by
law.

Your Rights Under The Privacy Rule
Following is a statement of your rights, under the Privacy Rule, in reference to your PHI. Please feel free to discuss any questions with
our staff.

You have the right to receive, and we are required to provide you with, a copy of this Notice of Privacy Practices - We are
required to follow the terms of this notice. We reserve the right to change the terms of our notice, at any time. Upon your request, we
will provide you with a revised Notice of Privacy Practices if you call our office and request that a revised copy be sent to you in the mail
or ask for one at the time of your next appointment. The Notice will also be posted in a conspicuous location within the practice, and if
such is maintained by the practice, on its web site.
You have the right to authorize other use and disclosure - This means you have the right to authorize any use or disclosure of PHI
that is not specified within this notice. For example, we would need your written authorization to use or disclose your PHI for marketing
purposes, for most uses or disclosures of psychotherapy notes, or if we intended to sell your PHI. You may revoke an authorization, at
any time, in writing, except to the extent that your healthcare provider, or our practice has taken an action in reliance on the use or
disclosure indicated in the authorization.

You have the right to request an alternative means of confidential communication – This means you have the right to ask us to
contact you about medical matters using an alternative method (i.e., email, telephone), and to a destination (i.e., cell phone number,
alternative address, etc.) designated by you. You must inform us in writing, using a form provided by our practice, how you wish to be
contacted if other than the address/phone number that we have on file. We will follow all reasonable requests.
You have the right to inspect and copy your PHI - This means you may inspect, and obtain a copy of your complete health record. If
your health record is maintained electronically, you will also have the right to request a copy in electronic format. We have the right to
charge a reasonable fee for paper or electronic copies as established by professional, state, or federal guidelines.

You have the right to request a restriction of your PHI - This means you may ask us, in writing, not to use or disclose any part of
your protected health information for the purposes of treatment, payment or healthcare operations. If we agree to the requested
restriction, we will abide by it, except in emergency circumstances when the information is needed for your treatment. In certain cases,
we may deny your request for a restriction. You will have the right to request, in writing, that we restrict communication to your health
plan regarding a specific treatment or service that you, or someone on your behalf, has paid for in full, out-of-pocket. We are not
permitted to deny this specific type of requested restriction.
You may have the right to request an amendment to your protected health information - This means you may request an
amendment of your PHI for as long as we maintain this information. In certain cases, we may deny your request.

You have the right to request a disclosure accountability - This means that you may request a listing of disclosures that we have
made, of your PHI, to entities or persons outside of our office.

You have the right to receive a privacy breach notice - You have the right to receive written notification if the practice discovers a
breach of your unsecured PHI, and determines through a risk assessment that notification is required. If you have questions regarding
your privacy rights, please feel free to contact our Privacy Manager. Contact information is provided on the following page under
Privacy Complaints.
How We May Use or Disclose Protected Health Information
Following are examples of uses and disclosures of your protected health information that we are permitted to make. These examples
are not meant to be exhaustive, but to describe possible types of uses and disclosures.

Treatment - We may use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services. This
includes the coordination or management of your healthcare with a third party that is involved in your care and treatment. For example,
we would disclose your PHI, as necessary, to a pharmacy that would fill your prescriptions. We will also disclose PHI to other
Healthcare Providers who may be involved in your care and treatment.
Special Notices - We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We may contact
you by phone or other means to provide results from exams or tests and to provide information that describes or recommends
treatment alternatives regarding your care. Also, we may contact you to provide information about health-related benefits and services
offered by our office, for fund-raising activities, or with respect to a group health plan, to disclose information to the health plan sponsor.
You will have the right to opt out of such special notices, and each such notice will include instructions for opting out.

Payment - Your PHI will be used, as needed, to obtain payment for your healthcare services. This may include certain activities that
your health insurance plan may undertake before it approves or pays for the healthcare services we recommend for you such as,
making a determination of eligibility or coverage for insurance benefits.

Healthcare Operations - We may use or disclose, as needed, your PHI in order to support the business activities of our practice. This
includes, but is not limited to business planning and development, quality assessment and improvement, medical review, legal services,
auditing functions and patient safety activities.

Health Information Organization - The practice may elect to use a health information organization, or other such organization to
facilitate the electronic exchange of information for the purposes of treatment, payment, or healthcare operations.
To Others Involved in Your Healthcare - Unless you object, we may disclose to a member of your family, a relative, a close friend or
any other person, that you identify, your PHI that directly relates to that person’s involvement in your healthcare. If you are unable to
agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest
based on our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, personal
representative or any other person that is responsible for your care, of your general condition or death. If you are not present or able to
agree or object to the use or disclosure of the PHI, then your healthcare provider may, using professional judgment, determine whether
the disclosure is in your best interest. In this case, only the PHI that is necessary will be disclosed.

Other Permitted and Required Uses and Disclosures - We are also permitted to use or disclose your PHI without your written
authorization for the following purposes: as required by law; for public health activities; health oversight activities; in cases of abuse or
neglect; to comply with Food and Drug Administration requirements; research purposes; legal proceedings; law enforcement purposes;
coroners; funeral directors; organ donation; criminal activity; military activity; national security; worker’s compensation; when an inmate
in a correctional facility; and if requested by the Department of Health and Human Services in order to investigate or determine our
compliance with the requirements of the Privacy Rule.

Privacy Complaints
You have the right to complain to us, or directly to the Secretary of the Department of Health and Human Services if you believe your
privacy rights have been violated by us. You may file a complaint with us by notifying the Privacy Manager at: MCRH, 12000 Elm
Creek Blvd N, Suite 350, Maple Grove, MN 55369.
We will not retaliate against you for filing a complaint.
THE MIDWEST CENTER FOR
REPRODUCTIVE HEALTH, P.A.
AND THE SUBSIDIARIES MCRH ALPHA, P.A.
AND GREAT PLANES REPRODUCTIVE
Phone 763.494.7700
CENTERS, P.A.
Toll Free 800.508.9763
Fax 763.494.7706
Web Site www.mcrh.com
Patient Authorization for Release of Medical Information

The Patient Authorization will give our office the authority to provide the person or entity you and your spouse/partner (if
applicable) designate on the form with access to your protected health information (PHI). The Patient Authorization is
limited to accessing only the information that you and your spouse/partner (if applicable) designate and does not give any
other rights to the person you have named on the form. Use of this form will enable us to provide your joint health
information to a person or entity that may be involved in your healthcare. Due to the nature of treatment received at MCRH
and its subsidiaries, records for patient and spouse/partner will be maintained jointly and this Authorization pertains to all
medical records regarding patient and spouse/partner (if applicable).
The following outline will describe the information we will need on the form and its purpose. Please address any questions
you have with our staff.
Directions for Completion of Authorization for Release of Medical Information Form
Patient Information: Please complete the entire section with patient demographic information.
Clinic/Health Provider: This identifies who is to provide the release of Protected Health Information.
Receiving Party: This information identifies a person or entity you and your spouse/partner (if applicable) have
authorized the Provider to release your PHI.
Description of Information to be Released: The type and amount of health information that we disclose is determined by
you and your spouse/partner (if applicable). We can disclose or provide access to all of your health information or it can be
limited to a specific item.
Release Type: This information tells us how you would like your PHI transmitted to a person or entity. Please see our
Medical Record Release and Payment policy for more information. If you wish to view your records, please contact
MCRH at 800-508-9763 to schedule a medical record review appointment.
Release Purpose: The purpose of your release of PHI is required to be documented by MCRH. This also helps us in
determining if a fee is applicable for reproduction of records.
Termination or Expiration: The Authorization will expire at the end of the calendar year of your last signature unless you
specify an earlier termination. You must renew or submit a new Authorization after the expiration date to continue the
Authorization. Please list the date of expiration if earlier than the end of the calendar year. You have the right to terminate
the Authorization at any time by submitting a written request to our Privacy Manager. Termination of this Authorization will
be effective upon written notice, except where a disclosure has already been made based on prior authorization. MCRH
may require a signed Authorization on disclosures.
Redisclosure Statement: The practice places no condition to sign the Authorization on the delivery of healthcare or
treatment. We have no control over the person(s) you have listed to receive your protected health information. Therefore,
your PHI disclosure under this authorization may no longer be protected by the requirements of the Privacy Rule and will
no longer be the responsibility of the practice.
Signature and Date: Because your medical records are kept jointly at MCRH, both patient and spouse/partner (if
applicable) will need to sign and date the Authorization. PHI on both parties will be released unless indicated under
Information to be Released.
Copies: We will provide you with a copy of this signed authorization upon request.
The Midwest Center for Reproductive Health, P.A. and its subsidiaries MCRH Alpha, P.A, and Great AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
PATIENT INFORMATION

Name: _________________________________________
Date of Birth:__________________

Address: _______________________________________
Day Phone: ___________________

City: _____________________________ State: _________________ Zip: _______________
CLINIC/HOSPITAL/
 Midwest Center for Reproductive Health, P.A. and its subsidiaries HEALTH CARE
PROVIDER
Name: __________________________________________________________________________
Address: _______________________________________
Day Phone: ___________________

City: _____________________________ State: _________________ Zip: _______________
RECEIVING PARTY
 Midwest Center for Reproductive Health, P.A. 12000 Elm Creek Blvd N, Suite 350, Maple Grove, MN 55369 Ph: 800-508-9763 Fax: 763-494-7766 Name: __________________________________________________________________________

Address: _______________________________________
Day Phone: ___________________

City: _____________________________ State: _________________ Zip: _______________
INFORMATION TO BE
 Any and all records (including ALL types of records listed below) RELEASED
**please review policy for details FEMALE:
 Operative report
 Blood tests including infectious disease results
MALE:
 Semen analysis results  Antisperm antibody results
Date Information is Needed: _______________ **please allow 7-10 business days for processing INSTRUCTIONS
**please review policy for details Release Method/Format Request: (check ONE) PURPOSE OF RELEASE
(Why this is needed?)
**applicable fees may apply to releases  This Authorization will expire at the end of the calendar year of your last signature below, unless you specify an earlier termination. You must renew or submit a new Authorization after the expiration date to continue the Authorization. Please list the date of expiration if earlier than the end of the calendar year: ________  You have the right to terminate this Authorization at any time by submitting a written request to our Privacy Manager. Termination of this Authorization will be effective upon written notice, except where a disclosure has already been made based on prior authorization.  The practice places no condition to sign this Authorization on the delivery of healthcare or treatment. We have no control over the person(s) you have listed to receive your protected health information. Therefore, your PHI disclosure under this Authorization may no longer be protected by the requirements of the Privacy Rule and will no longer be the responsibility of the practice.  Your signature indicated your authorization to release your PHI as described above. _____________________________________ __________________________
PATIENT SIGNATURE
SPOUSE / PARTNER / GUARDIAN SIGNATURE
DATE Copies of signed authorizations are available upon request.
Here is a mailing label to send your New Patient Forms and Release of Information to
MCRH prior to your new patient appointment.
Midwest Center for Reproductive Health 12000 Elm Creek Blvd N, Suite 350 Maple Grove, MN 55369

Source: http://www.mcrh.com/files/76115333.pdf