Patient Paperwork and Resources

Every patient who comes to RMA Florida for fertility care must complete and submit a medical intake form. This medical history will allow your physicians and care team to make the most accurate assessments possible concerning your fertility status, and this helps them devise the most effective treatment plans possible. Select the intake form that most appropriately describes you as a patient. Couples seeking services will need to complete patient intake forms for each partner.

Please review and complete the appropriate forms, then return them to our office one to two weeks prior to your first appointment. You may fax them to our office or drop them off in-person.

 

FEMALE INTAKE FORM

This is the Female Intake Form, depending on your health history. It should take you between five to ten minutes to complete.

Click here to download the form.

 

MALE INTAKE FORM

This is the Male Intake Form, depending on your health history. It should take you between five to ten minutes to complete.

Click here to download the form.

 

DEMOGRAPHIC FORM

This form collects your basic demographic information. It should take five to ten minutes to complete.

Click here to download the form.

 

SUMMARY HISTORY FORM

This form collects your infertility history. It should take five to ten minutes to complete.

Click here to download the form.

RMA Florida understands and acknowledges the need for our patients to have access to their personal medical records. Medical release authorization forms can be accessed and downloaded below. Depending on how you are submitting your request for medical records, please allow at least 1-2 weeks of processing time. Digital delivery like email or fax may take the shortest time, compared to hard copy requests that need to be mailed.

Completed medical release forms may be faxed to 407-804-9670 or dropped off in person at any RMA Florida location.

 

MEDICAL RECORD RELEASE FORM

Click here to download the form.

 

MENTAL HEALTH CARE AUTHORIZATION FORM

Click here to download the form.

 

HIPAA PRIVACY POLICY

Click here to download the form.

 

PATIENT CONSENT FOR USE OF ELECTRONIC MAIL

Click here to download the form.

All patients and partners must complete an intake form and all consent forms prior to your New Patient or Restart Patient Consultation. You can complete these forms by using RMA's Artemis Patient Portal App.

 

CREDIT CARD AUTHORIZATION FORM

MEDICAL RECORD RELEASE FORM

Click here to download the form.

 

Each patient who visits RMA is directed to complete and submit a medical intake form. These medical histories allow our physicians to make the most accurate assessments of your fertility status and devise the most appropriate treatment plans. Please select the intake form that most accurately reflects you as a patient. If you are seeking our services as an individual or couple, each partner in the couple must complete his or her own intake form.

Please complete the appropriate forms and return them to our office 1-2 weeks before your new patient appointment.

CREDIT CARD AUTHORIZATION FORM

Click here to complete the form.

 

MEDICAL RECORDS REQUEST FORM

Click here to complete the form.

 

PREGNANCY DISCHARGE RECORDS  RELEASE

Click here to complete the form.

 

CANCELLATION POLICY

As you know, waiting for an appointment to begin fertility treatment can be stressful, so we ask you to be considerate of other patients who are waiting for their appointment with RMA. To ensure every patient is satisfied, here at RMA, we have developed guidelines for canceling and rescheduling new patient appointments. Please review the following and call the patient liaison department at 973-656-2089 with any questions. If it becomes necessary for you to cancel your appointment, we require at least 72 hours notice so that we can contact other patients who may be able to take your scheduled appointment. If you do not contact us, RMA can bill you for the missed visit.

 

CANCELLATION RESCHEDULE POLICY

If you have canceled or rescheduled your appointment within 72 hours, RMA will ask you to complete a Credit Card Authorization Form for payment. This will ensure us of your commitment to your next rescheduled visit. You will be charged a $300.00 fee for the initial consultation fee, and when you come in for your consultation, you will be reimbursed this fee minus your co-pay.

 

CHILDREN IN WAITING ROOM POLICY

While creating families is RMA’s mission, your care is our #1 priority. For this reason, we ask that you please refrain from bringing children to appointments. This helps to ensure that the time you spend with your care team is completely focused on you and your journey and allows us to provide you with the best possible care.

We do our best to provide an environment sensitive to those trying to conceive. Please understand that the presence of children can also be distressing to those still working hard to make their dreams come true.

We are sensitive to the many emotions of infertility and appreciate our patients’ showing understanding by making separate childcare accommodations.

 

HIPAA PRIVACY POLICY

Click here to download the form.

Each patient who visits Reproductive Medicine Associates of Northern California is directed to complete and submit a medical intake form. These medical histories allow our physicians to make the most accurate assessments of your fertility status and devise the most appropriate treatment plans. Please select the intake form that most accurately reflects you as a patient. For instance, if you are struggling to conceive for the first time or have experienced multiple miscarriages, please select the Female Medical Intake form. If you are interested in Egg Freezing, please select the Elective Fertility Preservation form. If you are seeking our services as a couple, each partner in the couple must complete his or her own intake form.

Please complete the appropriate forms and return them to our office 1-2 weeks before your new patient appointment. They may be faxed to 415-644-0124 or dropped off in person. If you would like to send them electronically, please contact our patient liaison team for a secure email link at 415-603-6999.

 

FEMALE INTAKE FORM

This is the Female Intake Form, depending on your health history. It should take you between five to ten minutes to complete.

Click here to download the form.

 

MALE INTAKE FORM

This is the Male Intake Form, depending on your health history. It should take you between five to ten minutes to complete.

Click here to download the form.

 

DEMOGRAPHIC FORM

This form collects your basic demographic information. It should take five to ten minutes to complete.

Click here to download the form.

 

TRANSGENDER INTAKE FORM

This is the Transgender Intake Form. It should take five to ten minutes to complete.

Click here to download the form.

 

ELECTIVE FERTILITY PRESERVATION INTAKE FORM

This is the Elective Fertility Preservation Intake Form. It should take five to ten minutes to complete.

Click here to download the form.

 

MEDICAL FERTILITY PRESERVATION INTAKE FORM

This is the Medical Fertility Preservation Intake Form. It should take five to ten minutes to complete.

Click here to download the form.

 

OUTSIDE REFERRAL FORM

Click here to complete the form.

 

PATIENT CONSENT FOR USE OF ELECTRONIC MAIL
Click here to download the form.

 

COMMUNICATION FORM

Click here to complete the form.

 

Please complete the provided medical record release and send it to your OB/GYN, urologist, previous fertility center, or another medical provider to request your medical records.

We request a copy of your previous medical records to be forwarded to our office 1-2 weeks before your new patient appointment.

 

CANCELLATION POLICY

As you know, waiting for an appointment to begin fertility treatment can be stressful, so we ask you to be considerate of other patients who are waiting for their appointment with Reproductive Medicine Associates of Northern California. To ensure every patient is satisfied, here at Reproductive Medicine Associates of Northern California, we have developed guidelines for canceling and rescheduling new patient appointments. Please review the following and call the patient liaison department at 415-603-6999 with any questions: If it becomes necessary for you to cancel your appointment, we require at least 48 hour notice, so that we can contact other patients who may be able to take your scheduled appointment. If you do not contact us, Reproductive Medicine Associates of Northern California can bill you for the missed visit.

 

CANCELLATION RESCHEDULE POLICY

If you have canceled your appointment three times, Reproductive Medicine Associates of Northern California will ask you to complete a Credit Card Authorization Form for payment. This will ensure us of your commitment to your next rescheduled visit. You will be charged for the initial consultation fee and when you come in for your consultation, you will be reimbursed this fee minus your co-pay.

 

HIPAA PRIVACY POLICY

Click here to download the form.

All patients and partners must complete an intake form and all consent forms prior to your New Patient or Restart Patient Consultation. You can complete these forms by using RMA's Artemis Patient Portal App.

We recommend you request any pertinent medical records from your care providers and have them sent to the office of your scheduled appointment. You can find our contact information in your Welcome Email.

Download our Patient Education Handbook

Download Helpful Patient Education Materials

 

PATIENT CONSENT FOR USE OF ELECTRONIC MAIL

Click here to download the form.

 

MEDICAL RECORD RELEASE FORM

Please complete this form to request your records from RMA Philadelphia. Note: There is a fee for this request.

Click here to complete the form.

 

PREGNANCY DISCHARGE RELEASE FORM

Please complete this form to request your records from RMA Philadelphia to your OB/GYN.

Click here to complete the form.

 

HIPAA PRIVACY POLICY

Click here to download the form.

All patients and partners must complete an intake form and all consent forms prior to your New Patient or Restart Patient Consultation. You can complete these forms by using RMA's Artemis Patient Portal App.

Every patient who comes to RMA Southern California for fertility care must complete and submit a medical intake form. This medical history will allow your physicians and care team to make the most accurate assessments possible concerning your fertility status, and this helps them devise the most effective treatment plans possible. Select the intake form that most appropriately describes you as a patient. Couples seeking services will need to complete patient intake forms for each partner.

Please review and complete the appropriate forms, then return them to our office one to two weeks prior to your first appointment. You may fax them to our office or drop them off in-person.

 

FEMALE INTAKE FORM

This is the Female Intake Form, depending on your health history. It should take you between five to ten minutes to complete.

Click here to download the form.

 

MALE INTAKE FORM

This is the Male Intake Form, depending on your health history. It should take you between five to ten minutes to complete.

Click here to download the form.

 

DEMOGRAPHIC FORM

This form collects your basic demographic information. It should take five to ten minutes to complete.

Click here to download the form.

 

SUMMARY HISTORY FORM

This form collects your infertility history. It should take five to ten minutes to complete.

Click here to download the form.

 

FERTILITY PRESERVATION INTAKE FORM (ONCOLOGY PATIENTS ONLY)

This is the FPC Intake Form. It should take five to ten minutes to complete.

Click here to download the form.

 

TRANSGENDER INTAKE FORM

This is the Transgender Intake Form. It should take five to ten minutes to complete.

Click here to download the form.

 

Please click below to download the provided medical record release and send it to your previous fertility care provider, OB/GYN, urologist, or other medical providers to request your medical records.

It’s vital for us to receive a copy of your records one to two weeks before your new patient consultation. You can fax them to our office or drop them off in-person at your convenience. You can also contact our patient liaison team if you’d like to submit them electronically to our secure email address.

 

MEDICAL RELEASE FORM

Click here to download the form.

 

Reproductive Medicine Associates of Southern California understands and acknowledges the need for our patients to have access to their personal medical records. Medical release authorization forms can be accessed and downloaded below. Depending on how you are submitting your request for medical records, please allow at least 1-2 weeks of processing time. Digital delivery like email or fax may take the shortest time, compared to hard copy requests that need to be mailed.

Completed medical release forms may be faxed to 424-293-8842 or dropped off in person.

 

MEDICAL RECORD RELEASE FORM

Click here to download the form.

 

MENTAL HEALTH CARE AUTHORIZATION FORM

Click here to download the form.

 

These additional forms will be provided to you upon arrival at your new patient appointment. To assist in the efficiency during registration, you may elect to complete these forms below in advance.

Please complete all forms and return them to our office 1-2 weeks before your new patient appointment.

 

PATIENT CONSENT FOR USE OF ELECTRONIC MAIL

Click here to download the form.

 

HIPAA PRIVACY POLICY

Click here to download the form.

 

OUTSIDE REFERRAL FORM

Click here to download the form.

 

PATIENT NON-DISCRIMINATION-POLICY

Click here to download the form.

 

CANCELLATION POLICY

One of the most stressful parts of receiving fertility care is often waiting for an appointment. We ask you to be considerate of other patients who are waiting for an appointment at RMA Southern California by reviewing our guidelines concerning cancellations and rescheduling. If you have any questions about these policies, please contact our patient liaison department. Please remember that we require at least 48 hours notice if you must cancel your appointment. We’ll use this time to contact our other patients who may be able to take advantage of your appointment time. Please note that if you miss a visit at RMA Southern California without contacting us, we will bill you for the visit.

 

CANCELLATION RESCHEDULE POLICY

After three appointment cancellations, RMA Southern California will request that you complete a Credit Card Authorization Form for payment. This helps us ensure your commitment to your next rescheduled visit. You will be charged for the initial consultation fee, and after your consultation, we will reimburse this fee minus your copay.

 

UPDATE YOUR INSURANCE INFORMATION

If you are an existing patient and need to update the insurance information we have on file for you click here.