Making Priceless Affordable® Since 1997 www.cnyfertility.com | +1 (844) - 315 – BABY (2229)
Financial Welcome Packet
Welcome to CNY Fertility Center! We know the fertility treatment journey can be both exciting and challenging, and we're here to support you every step of the way, starting with the financial aspect of treatment. Some will come to CNY knowing they do not have any insurance coverage; others will come knowing they have some insurance coverage, but they may not be sure exactly what fertility coverage they have or where to begin
Our Patient Accounting team is here to help guide you through determining how much insurance coverage you may have and how much treatment will cost. In this packet, we have outlined information to help you prepare financially for your treatment.
While we do participate with most private health insurance plans, we understand insurance coverage may be limited. Insurance coverage for fertility is based on what your employer chooses to cover. Two patients may have insurance through the same insurance provider; however, their coverage may be very different based on what the employer has chosen to cover.
We HIGHLY RECOMMEND checking your insurance coverage by contacting your insurance provider directly to determine exactly what coverage you have for diagnostic tests and treatment.
We have included a guide (pages 9-13) to help you with determining your insurance coverage.
For those that have partial coverage or no insurance coverage at all for testing and/or treatment with CNY, we have listed pricing in this packet and on our website.
Keep in mind, our team will work with you regarding payment options. Please call our Patient Accounting Team with questions.
1-844-315-2229 Option 2
Monday-Wednesday and Friday 7:30am – 4:00pm EST and Thursdays 7:30am – 12:30pm EST
We look forward to working with you!
CNY Patient Accounting Team
WHAT SHOULD I DO BEFORE MY CONSULT?
Read this ‘Financial Welcome Packet’ in its entirety. Contact your insurance provider with questions related to possible coverage both at CNY and at any office you may have services performed.
Review the ‘Welcome Kit’ emailed to you for instructions related to your consult.
Upload to your Patient Portal a copy of your State issued ID (drivers License) for you and your partner (if applicable).
Upload a copy of the front and back of your medical and prescription insurance card(s). We must have a copy of the card to confirm any coverage and to bill insurance.
Call your insurance company to verify your insurance coverage (see pages 11-13).
Call your primary care physician for a referral, if needed.
Request your records from your previous fertility provider or OBGYN and upload the records to your Patient Portal (instructions on page 16).
Fill out your health information in your CNY Patient Portal https://www.cnyfertilitycenters.com/Patientportal
Recommended Review: https://www.cnyfertility.com/patient-resources/
• Review Dr Kiltz’s Fertility Family Building Guide https://www.cnyfertility.com/family-building-guide/
• Supplement Information
• Keto for Fertility Information
• Various Support Groups
You can review Private Pay pricing in this packet and online at: cnyfertility.com/affordability
Please be aware available services may differ per location; ask your Nurse Navigator after your consultation for more details.
All pricing and policies are subject to change at any time, without notice. Please contact Patient Accounting PRIOR to starting any treatments, to confirm current pricing.
Eff. 10/01/2025. Pricing and information subject to change, without notice.
Preconception Testing & Diagnostic Services for Private Pay Patients:
Pricing subject to change without notice*
New Patient Phone Consultation –“Telehealth” Phone Appointment
“Follow Up Talk” – Phone Appointment
HSG/“Dye Test”
Saline Sonogram (SIS)
CNY Fertility ‘In House’ Lab (bloodwork) Services
Semen Analysis
Sperm Freezing
PESA/TESE - Syracuse Office Only
Egg/Embryo/Sperm shipping between CNY Fertility locations
Endometrial Biopsy
Hysteroscopy & Endometrial Biopsy
ERA (Endometrial Receptivity Analysis)
$150.00
*$50.00 non-refundable booking fee required when scheduled, booking fee then credited to any out-of-pocket cost withy CNY.
$50.00
Please be advised that phone calls or text message conversations directly to Dr. Robert Kiltz (to his personal cell) may incur up to a $50 follow-up talk fee. We recommend you contact our office directly with general questions or concerns.
$275.00
$165.00
$300.00 or $25 per test
Includes: Estrogen, FSH, Progesterone, HCG, TSH, Free T3, Free T4, LH, AMH, Prolactin, Rubella, Vitamin D Patient also responsible for $8 lab draw fee (venipuncture) per appointment.
*Additional preconception blood tests that may be recommended, which would be sent to an outside laboratory (LabCorp or Quest). Patients are responsible for all fees billed to you by the outside laboratory.
$50.00
$100.00 - sample must be collected at home or in our office by appointment.
*Storage of frozen sperm $600/year, billed separately by CNY Cryo Inc.
$1,100.00 + $220.00 if sperm is frozen, following this procedure.
*Storage of frozen sperm $600/year, billed separately by CNY Cryo Inc.
$75.00 Shipping Fee within NY State
$405.00 Shipping fee from one state to another
$165.00 *Pathology/ERA fees not included
$1,215.00 includes Anesthesia. Pathology fees not included
*If a sample is obtained from any biopsy/surgery and sent for pathology, the outside laboratory will bill you directly
$795.00 *Approximate Ingenomix fee - paid by patient directly to Ingenomix.
$165.00 to CNY Fertility, for the endometrial biopsy
Cycle Monitoring fee(s)
*All ERA cycles will incur an additional $995.00 in office monitoring fee OR a $150.00 cycle management fee.
Treatment Pricing & Payment Plan Details for Private Pay Patients:
Pricing subject to change without notice*
Treatment
In-Office Cycle Monitoring Fee
Cycle Management Fee
Pricing + Details
$995.00, per cycle
*Does not include pregnancy test(s) or prenatal care.
Includes: Cycle Management, Ultrasounds & Bloodwork (Estrogen, FSH, Progesterone, Prolactin, LH, TSH, Testosterone, HCG, AMH, T3, T4 - as ordered by CNY) from Baseline until procedure date (IUI, Egg retrieval or FET) only.
Washes, Infusions, diagnostic testing, genetic testing or any laboratory work sent to LabCorp or Quest, are NOT included in this monitoring fee.
$150.00, per cycle (any cycle type) *Not billable to insurance*
This fee is assessed to all clients monitoring outside of CNY Fertility. Patient responsible for all fees charged by the outside clinic for any lab work/ultrasounds performed.
Intra-Uterine Insemination (IUI): $650.00
Includes: sperm wash and prep and (1) insemination. Medications and monitoring are NOT included.
In-Vitro Fertilization (IVF):
$4,500.00
Includes: anesthesia, egg retrieval, ICSI fertilization, assisted hatching, embryo glue, one fresh embryo transfer and cryopreservation. *Storage is NOT included and will be billed to you at $600.00 per year, per sample type, by CNY Cryo Inc. Medications and monitoring are NOT included in this price.
Frozen Embryo Transfer(s) are discounted to $995.00 per transfer, within 12 months of the private pay IVF cycle.
ZYMOT Device (specialty order PRIOR to IVF start)
Embryo Biopsy with a Fresh IVF
Biopsy of Previously Frozen Embryo(s)*
Fertility Preservation:
Oocyte (egg) Freezing
$200.00, plus all IVF Fees.
$200.00 per embryo
$350.00 per embryo *Advanced payment & scheduling required.
$3,500.00
Includes: anesthesia, egg retrieval, cryopreservation of mature eggs. Storage is NOT included and will be billed to you at $600.00 per year, per sample type, by CNY Cryo Inc.
Frozen Embryo Transfer (FET): Our standard self pay (private pay) rate is $2,495.00 Medications and monitoring are NOT included in this price. If embryo(s) were shipped to CNY, a ‘thaw kit’ may be required for additional $200.
Eff. 10/01/2025. Pricing and information subject to change, without notice. 5
Private Pay IVF and Medication Bundles
*CNY Fertility Exclusive Packages* Pricing as of 10/01/2025 and subject to change without notice
IVF & Medication Package
Egg Banking & Medication Package
$6,800.00*
$5,300.00*
IVF Package above includes Follistim, Provera, Ganirelix, Micro-dose hCG, Lupron Trigger, Pregnyl, Letrozole, Prometrium, PIO, and Estrace*
Egg Freezing Package above includes Follistim, Provera, Micro-dose hCG, Lupron Trigger, Pregnyl, Letrozole*
*Some medications may be filled in their generic form by the pharmacy. They are just as effective and safe as brand-name and help make your package as affordable as possible.
These medication packages are based on an average stimulation of 10 days. Please contact our office after your consultation to discuss the amount of medication in the package. Additional medications may be needed based on individual responses or medical protocols and will need to be purchased outside of the package by the patient.
Fees must be paid to CNY directly, prior to medications being ordered. Not billable to medical/prescription insurance.
Pre-Implantation Genetic Testing (PGT) with IVF:
This service can be added to your IVF cycle, PRIOR to starting your IVF treatment. CNY performs the biopsy of embryo(s) and sends those sample(s) to an outside laboratory, Cooper Genomics, for genetic testing.
After your consultation, a nurse can send a request to Cooper, and they will then contact you and review fees.
CNY does NOT finance PGT biopsy and testing fees. Please be prepared to pay CNY and Cooper’s fee(s) in full.
Embryo biopsy with a fresh IVF, $200.00 per embryo
Embryo biopsy of previously frozen Embryo(s), $350.00 per embryo
Eff. 10/01/2025. Pricing and information subject to change, without notice.
Additional Treatment Services – Private Pay Pricing
Your treatment may consist of services & procedures outside of the IUI, IVF or FET procedure and monitoring alone. Please review our private pay fees below:
HCG Wash (uterine wash)
Intralipid Infusion
IVIG Infusion
PRP - Platelet Rich Plasma, Uterine Infusion
PRP – High Volume Uterine Infusion
PRP – Intra Ovarian Injection
$50.00
$100.00
$150.00
$300.00 per infusion
$600.00 per infusion
*Medication not included; patient must supply.
*Medication not included; patient must supply.
*Medication not included; patient must supply.
*Not billable to insurance.
*Not billable to insurance.
$1,600.00 includes anesthesia
Pregnancy Test(s) and/or Prenatal Care:
Blood work
Prenatal Ultrasound
*Not billable to insurance.
$25.00 per test/hormone + $8.00 lab draw fee
Example: HCG, Progesterone = $58.00
$165.00 per ultrasound
Eff. 10/01/2025. Pricing and information subject to change, without notice.
Patients Using Private Medical Insurance for Services
Please contact your insurance company and request an overview of your coverage prior to all appointments. We have included a guide for you to contact your insurance. (See Insurance Coverage Questionnaire on next pages ) It is the patient(s) responsibility to understand their insurance coverage, policy exclusions, and any authorization requirements, prior to beginning treatment. Most policies have specific criteria patients must meet to be eligible for IVF coverage.
If your policy requires preauthorization, you must notify our office at least two weeks prior to starting EACH treatment cycle or before scheduling any diagnostic and/or surgical procedure. You can notify our team by calling Patient Accounting or by sending correspondence through your Patient Portal to: Patient Accounting Please describe your treatment intents and timeline. *Authorization requests can take 14+ business days to process. Please plan accordingly.
Failure to notify our team can result in delayed cycle start and/or denial of claims.
IMPORTANT INFORMATION REGARDING PRIOR-AUTHORIZATION REQUIREMENTS:
We strongly recommend you obtain your insurance company’s medical policy to review coverage criteria, prior to starting treatment. Coverage is based on your policy guidelines and medical necessity.
Medical records/lab results typically required for the prior authorization process:
• Estradiol and FSH blood tests – drawn on day 3 of your cycle.
• AMH (anti-mullerian hormone)
• HSG/SIS/Uterine Cavity Evaluation, within the last 6 months.
• Semen Analysis for Male partner (If SA is abnormal, a repeat test may be required by your insurance).
• Complete history of prior fertility testing and/or treatment cycles.
• If you are a prior IVF patient – report of all embryo(s) in storage. (Your insurance company may require you to utilize frozen embryo(s) before moving forward with new IVF cycles. *review your policy for details*
CNY requires a copy of your insurance card (front and back), to request authorizations and send claims to your insurance. Please be sure your correct name, address, phone number and social security are on file with our office. (You can update this information securely via your patient portal).
CNY Fertility will NOT be responsible for your denied claims, should you fail to notify CNY in advance and allow time to process this prior authorization. If Prior Authorization is not on file before your cycle, you could be responsible for ALL costs of your treatment. Please understand that CNY and your insurance may need at least two weeks to process your request but some requests can take longer Please do not start your cycle without authorization and review of coverage.
Billing decisions, either insurance or self-pay, must be made prior to the start of your cycle.
*If you have insurance coverage for services but wish to NOT have your insurance billed due to a deductible or high coinsurance (as example), you must notify our financial office in advance of your cycle. A “Do not bill insurance waiver” must be signed and payment is required PRIOR to services. Once claims are submitted to your insurance, CNY will not retract the claims due to your out-of-pocket charges
Insurance Coverage Worksheet:
This quote may not guarantee benefits or coverage. You and CNY can be misquoted benefit information. Insurance Company: ______________________ Policy/Member ID #: _____________________
Who is covered under the policy: ☐ self ☐ partner ☐ both
Who is the policyholder? ☐ self ☐ partner
☐ I am a dependent under ___________(name) ______(date of birth)
*Is this your ONLY active medical insurance? ☐ YES ☐ NO
*If no, is this policy PRIMARY or SECONDARY. If you have two insurance policies, you must provide our office with both the primary and secondary insurance information. Failure to supply the office with your primary insurance will result in full denials by your secondary insurance and patient responsibility.
Is a Referral Required from my Primary Care Physician? ☐ YES ☐ NO
What is my Deductible: $___________
How much of my deductible have I met this year? $ _________ as of (date) ___ /___ /___
Do I have an ‘out of pocket maximum’: $___________
Do I have a Co-Pay per visit: $_______ for Specialist Office Visit
$______ for bloodwork/ labs
$_______ for radiology/ultrasounds
Do I have to pay a % of my diagnostic testing and office visit(s) once my deductible is met? %
Is there a preferred laboratory I should go to for bloodwork? ☐ Lab Corp ☐ Quest ☐ Other:_________
*If your insurance requires use of specific lab, you must notify our office in advance of each bloodwork appointment. CNY Fertility routinely sends bloodwork to LabCorp. If LabCorp is not in your insurance network, you may have additional costs.
Does my policy have an Infertility Age Limit? ☐ YES _____________ ☐ NO
Is the CNY Fertility location of choice, ‘IN NETWORK’ with my policy? ☐ YES ☐ NO
• If no, do I have out of network benefits? ☐ YES ☐ NO
If I do have out-of-network benefits, do I need to pay a higher percentage of my care? ☐ Yes ___ % ☐ No
While speaking with your insurance company, they may ask for a billing (CPT procedure) code.
This is a 5-digit code used by the insurance company to determine if something is covered. We have included those CPT codes for services below. Please use this as a guide to explore your coverage.
Below are the commonly used diagnosis codes for testing and/or during a cycle.
Common diagnosis code used for DIAGNOSTIC/PRECONCEPTION TESTING orders:
o Z31.41 Procreative Management/Testing or N97.9 Female Infertility
Diagnosis code used for monitoring services with IUI/IVF/FET cycles and with all IUI/IVF/FET procedures:
o Z31.83 Encounter for ART procedure cycle
Eff. 10/01/2025. Pricing and information subject to change, without notice.
Preconception Blood Testing:
Blood Type & Rh Antibody Screen (86900) CBC w/o Diff (85027) CMP (80053)
Anti-Mullerian Hormone/AMH (82166) Rubella IgG (86762) Varicella (86787)
Prolactin (84146)
RPR (86592)
Testosterone (84403) Vitamin D (82306)
TSH (84443) T3 (84481) T4 (84439)
Hepatitis B Surface Antigen (87340) Hepatitis C Antibody (86803) HIV ½ Antibody (87389)
Preconception Genetic Testing:
Expanded Carrier Screening – Beacon Expanded Carrier Screening PLUS Panel, offered in our CNY office, will be sent to LabCorp. Please be sure this lab is network with your insurance. This panel may not be covered by most insurance plans. (CPT Code: 81443)
Karyotype (88262) Chromosome (88230)
Is prior authorization required for preconception genetic testing? ☐ YES ☐ NO
Additional Preconception/Fertility Testing:
HSG (dye test): (CPT Codes: 58340, 74740, 76830, 76831) Covered? ☐ YES ☐ NO
*Prior authorization or Referral Required? ☐ YES ☐ NO
Semen Analysis for male partner: (CPT Codes: 89310/89320) Covered? ☐ YES ☐ NO
*Prior authorization or Referral Required? ☐ YES ☐ NO
*Male partner must be listed on the policy, to be billable to the insurance.
Treatment Coverage/ART (Assisted Reproductive Technology) Coverage:
Do I have coverage for IUI – Artificial Insemination? Details/Limits: ___________________________
CPT Codes: 58322, 89260, 89261, 89353 (If applicable: Sperm Thaw 89353)
Preauthorization Required? ☐ YES ☐ NO
IVF – In-Vitro Fertilization? Details/Limits: _____________________________
*What requirements must be met for IVF coverage to be considered? (Minimum # of IUI’s for example)
Preauthorization Required? ☐ YES ☐ NO
CPT Codes: 58970, 58974, 76705, 76948, 89250, 89272, 89280, 89281, 89253, 89254, 89255, 89258, 89342, 89261
*Assisted Hatching (89253) & Embryo Cryopreservation (89258) with IVF - Covered? ☐ YES ☐ NO
Biopsy of Embryo(s) for genetic testing with IVF?
(Biopsy performed by CNY Fertility. Genetic Testing by outside laboratory, Cooper Genomics)
Biopsy for PGD CPT Code: 89290, 89291
Genetic testing- CPT Code: 81228/99000 PGT-A, 88299 PGT-M
Preauthorization Required? ☐ YES ☐ NO
Preauthorization Required? ☐ YES ☐ NO
Details/Limits:
*If patient and/or partner have previously undergone voluntary sterilization (tubes tied or vasectomy): Will Infertility coverage be available following voluntary sterilization? ☐ YES ☐ NO
- Continued next page -
Eff. 10/01/2025. Pricing and information subject to change, without notice. 11
Coverage for a FET – Frozen Embryo Transfer? (CPT Codes: 76857, 76830, 89352, 89253, 89255, 58974, 58976)
Coverage Details/Limits:
Preauthorization Required? ☐ YES ☐ NO
*Assisted Hatching with FET (CPT: 89253) Covered? ☐ YES ☐ NO
Storage of frozen sperm/egg(s)/embryo(s)/testicular tissue: Annual storage fee is $600.00 when not covered by insurance and will be billed to you by Embryo Options/CNY Cryo Inc, upon that sample being received and/or frozen at a CNY office.
Embryo Storage (89342)
Sperm Storage (89343)
Egg/Oocyte Storage (89346)
Do I have coverage for fertility medications: ☐ Yes ☐ No
Covered? ☐ YES ☐ NO
Covered? ☐ YES ☐ NO
Covered? ☐ YES ☐ NO
Do fertility medications require a prior authorization: ☐ Yes ☐ No (example of fertility medications: Gonal F/Folllistim, Cetrotide/Ganirelix, HCG/Pregnyl, Lupron) Is there a preferred pharmacy for fertility medications, per this insurance?
DATE/TIME of call: ____________ Insurance Representative Name: REFERENCE # FOR YOUR CALL:
*Name of Rep and Reference # are needed, should you not be quoted accurate information
Please note:
CNY Fertility does NOT participate with any Medicaid or Marketplace Insurance products. If our office does not participate with your insurance, you will be considered a ‘self pay’ / private pay patient.
Not all CNY locations participate in the same insurance networks.
Please check that the location and Doctor you plan to see, is in network.
Eff. 10/01/2025. Pricing and information subject to change, without notice. 12
Understanding Health Insurance Terms:
Excluded: Services that are excluded are non-covered by your insurance policy.
Medical Necessity: Refers to a decision by your health plan, that your treatment, test, or procedure is necessary for your health or to treat a diagnosed medical problem. It is important to remember that what you or your doctor defines as medically necessary may not be consistent with your health plan’s coverage rules. Before you have any procedure, especially one that is potentially expensive, review your benefit handbook to make sure it is covered. If you are not sure, call your health plan’s customer service representative.
Prior Authorization Required: If your policy requires pre/prior authorization for your medication or treatment, this must be in place BEFORE your treatment cycle begins and even before fertility medications are dispensed from the pharmacy. You must allow 10-14+ business days for the process to be completed. CNY Fertility is not responsible for your failure to notify our office, in writing, should your policy require authorization for medications or treatment. Please send a WEB CORRESPONDENCE to Patient Accounting to request an authorization of services with your insurance.
Co-insurance: This is a portion of a covered service you are responsible for. *Example: Coverage at 80% means that the insurance company will pay 80%, and you will be required to pay the other 20% of the allowed amount.
Co-payment: Your co-payment is a fixed amount that you, the insured, must pay at the time of service. Copayments may be due for office visits, laboratory testing, radiology and medications.
Deductible: Your deductible is the amount you will be responsible for before the insurance will pay for covered services. This is typically a yearly amount, so when the policy starts again, usually each calendar year, the deductible will reset. You may have individual and/or family deductible amounts.
Out-of-Pocket Maximum: The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered services. It does not include anything you may spend for services your plan doesn't cover.
Lifetime Maximum: This is the number of attempts or dollar limit your health insurance policy will pay for the entire life. If you have a lifetime maximum, please keep track of your maximum with your insurance carrier to ensure funds are available before proceeding with treatment.
EOB - Explanation of Benefits: An EOB is a statement from your health insurance plan describing what costs it will cover for medical care or products you’ve already received. The EOB is generated when your provider submits a claim for the services you received. The insurance company sends you EOBs to make clear: the cost of care you received, how much the provider was paid and any out-of-pocket medical expenses you’ll be responsible for. (Dr’s office will then bill you any of those fees due from the patient.)
Network: The group of doctors, hospitals, and other health care professionals that a managed care plan has contracted with to deliver medical services to its members.
Out-Of-Network: Services you receive are considered out-of-network when you use a doctor or other provider that does not have a contract with your health plan. When you go to an out-of-network provider, benefits may not be covered or may be covered at a lower level. You may be responsible for all or part of the bill when you use out-ofnetwork providers.
Preferred Laboratory: This is the laboratory you are required to use for in-network coverage. Failure to notify your nurse of the preferred laboratory may result in samples being sent to an out-of-network laboratory. Patient is responsible for all lab fees.
Preferred Pharmacy: This is the PHARMACY you are required to use for in-network coverage. Failure to notify your nurse of the preferred pharmacy, may result in coverage being denied or a higher out of pocket expense to the patient. CNY Fertility does not process your medication claims, please be sure the pharmacy you are using is IN NETWORK, when using your medical/prescription insurance.
Eff. 10/01/2025. Pricing and information subject to change, without notice.
How to send records to CNY:
Medical Records Release Forms - see Pages 15-18 of this packet. Please complete the Medical Records release form and send to your previous physician, to have any records sent to CNY Fertility.
CNY Fertility, Patient Records Department: Fax # 315-883-8916
Email: medicalrecords@cnyfertility.com
Please note - When discharged from CNY, you will need to complete another records release, to have your CNY records sent to another office or OBGYN. We cannot send records without a signed records release form.
Please fax or email all completed record release forms to our team and allow up to 5 business days for processing.
If you already have access to your records:
1. Upload your medical records to your patient portal directly.
2. Upload medical file to our secure link: https://www.encyro.com/medrecords
*Our team will receive your file and add it to your chart
Eff. 10/01/2025. Pricing and information subject to change, without notice.
AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION/MEDICAL RECORDS
An additional authorization (NYS DOH - 5032) is required for disclosures when your medical records contain information relating to Alcohol and/or Drug Treatment, Mental Health Treatment, or Confidential HIV/AIDS information including but not limited to test results and the fact that the test was taken.
Patient Name:
Patient Address: City State Zip Code
Patient Date of Birth: ______/______/______ Phone #: (_____) _______ -
Medical Record Number:
I hereby authorize:
□ CNY Fertility, PLLC
Client Email Address:
□ Other Healthcare Provider (specify NAME): Address and phone/fax numbers: ____________________________________________
To release:
□ Protected Health Information and/or
□ Sensitive Protected Health Information (HIV/AIDS-related information, Substance Abuse Treatment, or Mental Health Treatment information) *REQUIRESCOMPLETIONOFADDITIONAL AUTHORIZATIONFORMNYSDOH-5032(lastpage)
Pertaining to my (check one or more as applicable):
□ Outpatient / Office Visit(s) (date range) ____/____/____ to ____/____/____
□ Hospital Admission (discharge date) ____/____/____
□ Emergency Department visit (date) ___/___/___
□ Ambulatory/Outpatient admission (date) ___/___/___
□ All medical records related to Fertility Treatments Date(s) of treatment
I authorize disclosure of the following information from my medical record (check, where applicable list type and date):
□ History & Physical _______________________________
□ Lab Test Results & Reports _______________________
□ Radiology & Imaging Reports ______________________
□ Clinical Documentation ___________________________
□ Pathology Reports _______________________________
□ Operative Reports _______________________________
□ Discharge Summary
□ Billing Records __________________________________
□ Image (of Client and/or Client’s Child) and other Client-Identifiable Information
□ Other (describe) OR
□ Entire copy of medical record
- Continued on pages 16-18
Eff. 10/01/2025. Pricing and information subject to change, without notice. 15
From my medical records to:
Name of organization or person:
Address:________________________________________________________________ apt . #:_______________________
City:____________________________________________________State
Zip Code:_____________________
Telephone (Area Code and Number):_____________________________
Fax (Area Code and Number):_________________________
Organization or Person Email Address:
The purpose(s) for which disclosure is authorized (check where applicable):
□ Medical Care
□ Insurance Coverage
□ Personal
□ CNY Fertility, PLLC Subsidized Marketing Communications
□ For Use on CNYFC Social Media Platforms
□ Other (specify)____________________________________________________
I understand that:
1. CNY Fertility, PLLC will not condition treatment, payment for services, or eligibility for services on whether I provide Authorization for any requested disclosure by CNY Fertility, PLLC.
2. I may inspect or receive a copy of the Protected Health Information described by this Authorization upon payment of a reasonable fee as described in our Notice of Privacy Practices.
3. This Authorization is voluntary and that I have the right to refuse to sign it.
4. PHI released pursuant to this authorization may include records generated by another healthcare provider or facility which are now part of my CNY Fertility, PLLC medical record.
5. I may revoke this Authorization at any time by providing a written notice of revocation as specified by the Notice of Privacy Practices; however such revocation would not affect any action taken by CNY Fertility, PLLC in reliance on this Authorization before receipt of my written revocation.
6. This Authorization will expire on ____/____/____ (fill in date if less than 1 year) or 1 year after being signed.
7. The information disclosed pursuant to this Authorization, except information protected by Federal and/or State regulations about confidentiality of drug and alcohol abuse records, HIV and Mental Health, may be subject to redisclosure by the recipient and no longer protected by federal privacy regulations or other applicable state or federal laws.
8. My medical records may contain genetic testing information including test results.
9. I have the right to receive a copy of this authorization.
Signature of client/personal representative (e.g., legal guardian) Date
Print name (If personal representative, indicate relationship to client)
Witness or Notary (This Authorization must be notarized if information is being released to an attorney and/or court.)
Eff. 10/01/2025. Pricing and information subject to change, without notice. 16
Authorization for Release of Health Information (Including Alcohol/Drug Treatment and Mental Health Information) and Confidential HIV/AIDS-related Information
NEW YORK STATE DEPARTMENT OF HEALTH
Patient Name
Patient Address
Date of Birth Patient Identification Number
I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form.
I understand that:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG TREATMENT, MENTAL HEALTH TREATMENT, and CONFIDENTIAL HIV/AIDS-RELATED INFORMATION only if I place my initials on the appropriate line in item 8. In the event the health information described below includes any of these types of information, and I initial the line on the box in item 8, I specifically authorize release of such information to the person(s) indicated in item 6.
2. With some exceptions, health information once disclosed may be re-disclosed by the recipient. If I am authorizing the release of HIV/AIDS-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from re-disclosing such information or using the disclosed information for any other purpose without my authorization unless permitted to do so under federal or state law. Any unauthorized further disclosure of HIV/AIDS-related information in violation of state law may result in a fine or jail sentence or both. For alcohol and substance abuse re-disclosure, Federal Confidentiality rules (42 CFR part 2) restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. A general authorization for the release of medical or other information is NOT sufficient authorization for further disclosure. If I experience discrimination because of the release or disclosure of HIV/AIDS-related information, I may contact the New York State Division of Human Rights at 1-888-392-3644. This agency is responsible for protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the provider listed below in item 5. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.
4. Signing this authorization is voluntary. I understand that generally my treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditional upon my authorization of this disclosure. However, I do understand that I may be denied treatment in some circumstances if I do not sign this consent.
5. Name and Address of Provider or Entity to Release this Information:
6. Name and Address of Person(s) to Whom this Information Will Be Disclosed:
7. Purpose for Release of Information:
8. Unless previously revoked by me, the specific information below may be disclosed from: until INSERT START DATE INSERT EXPIRATION DATE OR EVENT
☐ All health information (written and oral), except:
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For the following to be included, indicate the specific information to be disclosed and initial.
☐ Records from alcohol/drug treatment programs
☐ Clinical records from mental health programs*
☐ HIV/AIDS-related information
9. If not the patient, name of person signing form:
Information to be Disclosed Initials
10. Authority to sign on behalf of patient:
All items on this form have been completed, my questions about this form have been answered and I have been provided a copy of the form.
SIGNATURE OF PATIENT OR REPRSENTATIVE AUTHORIZED BY LAW
Witness/Statement Signature:
DATE
I have witnessed the execution of this authorization and state that a copy of the signed authorization was provided to the patient and/or the patient’s authorized representative.
PERSON’S NAME & TITLE SIGNATURE
DATE
This form may be used in place of DOH-2557 and has been approved by the NYS Office of Mental Health and NYS Office of Alcoholism and Substance Services to permit release of health information. However, this form does not require health care providers to release health information. Alcohol/drug treatment-related information or confidential HIV-related information released through this form must be accompanied by the required statements regarding prohibition of re-disclosure.
* NOTE: Information from mental health clinical records may be released pursuant to this authorization to the parties identified herein who have a demonstrable need for the information, provided that the disclosure will not reasonably be expected to be detrimental to the patient or another person.
DOH-5032(4/11)
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