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Ivftampa.com

Reproductive Health Associates
Reproductive Endocrinology and Infertility 2919 W. Swann Ave #307
813-872-0018 phone
900 Carillon Pkwy #301
Tampa, FL 33609
813-876-1149 fax
St. Petersburg, FL 33716
Frozen Embryo Self Pay Fee Agreement

Patient Name: _____________________________________________________________________________
Date:_________________________________________ Account # ___________________________________
IVF Coordinator: ____________________________________________________________________________

The basic cost of your customized IVF cycle will be $3650.00 and is required to be paid in full at the time of your consult
appointment. The above price includes all monitoring visits, consisting of ultrasounds and estradiol blood work, egg transfer, embryology, and the first pregnancy test. Any pretesting visits, ultrasounds, and blood work required before the start of your planned transfer is not included in above price and will be required to be paid at time of service. If you have diagnostic infertility insurance coverage; we will file the pretesting charges with your insurance, but you will be responsible for any amount not covered by your Schedule of Procedure:
____________ This is day 1 of your menses (period). You wil begin Estrace 2mg in the Morning and Evening.
____________ This is day 10 and/or day 13 of your menses. You will need to come to the office for a vaginal ultrasound
____________ This is day 15 of your menses. You will begin Progesterone. One injection in the evening 0.75mg = 1 ½ cc
____________ This is day 17 or day 19. Your Frozen Embryo Transfer will occur today. You will need to call the office to
schedule a pregnancy test for 14 days after the procedure. A morning blood draw should be schedule to ensure we receive your results the same day. ____________ This is 14 days after your transfer. Today is the day of your pregnancy test at the office.
Required Additional Charges:
 Medications required for transfer, payable to the pharmacy  Saline Ultrasound (SHG) paid at time of service  Administration Fee (if applicable) $ _________ The total cost of your above listed customized Frozen Embryo Transfer wil be $ __________________
Reproductive Health Associates and its employees make all efforts to advise you of your insurance benefits quoted to us by your insurance company. We do not accept any obligation to the validity of these benefits as they are the responsibility of your insurance company and you. It is your responsibility to assume all balances not covered by your Completing a transfer does not in any way guarantee pregnancy. In some cases multiple transfers will need to be completed to obtain pregnancy. If your transfer is cancelled by Dr. Cowart for any reason the unused portion of your fee By signing below I attest that I have read, had an opportunity to ask questions, understand, and agree to the
information, terms, and fees listed above:
___________________________________________________________
________________________________
Patient Signature
___________________________________________________________
________________________________
Witness Signature

Source: http://www.ivftampa.com/resources/IVF-Frozen-Embryo-Transfer-Self-Pay.pdf

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