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
Category School reports on Year 12 outcomes – media publication and supporting The 2005 school reports on Year 12 outcomes will be published in Queensland metropolitan and regional newspapers on Monday 3 April 2006. The data will also be published on the QSA website at 12 noon on the same day. Attached are some questions and answers about the public release, possible uses and inte
Medical best practices for the treatment of torture survivors Richard F. Mollica, M.D.* Introduction cological problems. A head injury might be-Accurate identification of torture survivors, come evident during the neurological review including a history of the torture experi-and the physical sequelae of a burn injury ences and injuries, is essential for the medi-will emerge during