Click here to download the Notice of Privacy Practices.
I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: 1) Conduct, plan and direct my treatment and follow-up a month the multiple healthcare providers who may be involved in that treatment directly and indirectly. 2) Obtain payment from third-party payors. 3) Conduct normal healthcare operations.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand that you are not required to agree to my requested restrictions but if you do agree, then you are bound to abide by such restrictions.
I/We agree that the physicians and staff of the Fertility Center of Las Vegas/Ovagen Fertility/Granite Surgery Center may contact me/us after my/our treatment is completed for any of the following purposes (such contact may be by telephone, mail, email, or other suitable communication):
Our mailing list is never sold and we do not send spam. You may opt-out at any time.
Email offers an easy and convenient way for patients and doctors to communicate. In many circumstances, it has advantages over office visits or telephone calls. But remember: there are important differences. Email is not the same as calling our office: there is no person at the other end of the call – just a computer. You can’t tell for certain when your message will be read, or even if your doctor is in the office or on vacation. Nonetheless, we believe that the ease of communication email affords is a benefit to patient care. It will further assist us if you could identify the nature of your request in the subject line of your message. Below are our rules for contacting us using email:
By my selection and signature below I consent to communicate with my doctor electronically. I have read the above information and understand the limitations of security on information transmitted. I understand that my doctor may not be able to communicate with me electronically about my specific condition if I live outside of the state in which my doctor is licensed. Finally, either one of us can revoke permission to use the email system at any time.
I/We, the undersigned, hereby authorize payment of medical benefits to Fertility Center of Las Vegas (FCLV)/Ovagen Fertility/Granite Surgery Center (GSC) for services rendered.
I/We understand that FCLV is affiliated with GSC. GSC is not contracted with any insurance companies and therefore GSC charges will not be billed to an insurance company. I understand that I may receive separate bills from GSC and that I will be financially responsible for all fees associated with GSC. Surgical procedures associated with GSC include hysteroscopy, sonohysterogram under sedation, D&C, cyst aspirations, egg retrieval and embryo transfers.
I/We also authorize FCLV/GSC/Ovagen Fertility to release any medical records in the course of my/our examination or treatment to our insurance companies. The assignment will remain in effect, until revoked by me/we in writing. A photocopy of the medical records is to be considered as valid as the original.
I/We hereby agree to be financially responsible for all charges incurred. I/We understand that if my/our insurance company denies any of my/our claims for any reason that I/We are responsible for the full amount of services rendered.
In the event my/our account is referred to a collection agency due to non-payment, I/We agree to pay all collection and legal fees that are incurred. Once an account is sent to any collection agency, you will need to contact the collection agency prior to making any future visits.
I/We understand that a $36.00 NSF charge will be added to my/our account for each returned unpaid check. If the same check is returned a second time, I/We understand it may be referred to a collection agency for recovery.
I/We have read and understand the financial policies for The Fertility Center of Las Vegas/Ovagen Fertility/Granite Surgery Center.
Call Us Toll Free
+1 (800) 509-7174
8851 W. Sahara Avenue Suite 100
Las Vegas, NV 89117
2769 Sunridge Heights Parkway Suite 100
Henderson, NV 89052