1. health and fitness
2. disease

Idaho Ceenter for Reprodu
uctive Med
dicine
11
11 Main Streeet Suite # 100 / Boise, ID 833702 (208) 3442-5900.
PA
ATIENT INF
FORMATIO
ON/INFORM
MACIÓN DE PACIENTE
E
PATIEN
NT/PACIENTE
PA
ARTNER/PARE
EJA
SOCIAL SECURIT
TY NO./NUMERO DE SEGUR
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SOCIAL SEC
CURITY NO. / NUMERO DE S
SEGURIDAD SOCIAL
NAME (FIRST, MID
DDLE INITIAL, LAST) / NOMBRE (PRIMERO, INITIAL, AP
PELLIDO)
NAME (FIRST
T, MIDDLE INITIAL, LAST) / NOMBRE (PRIMERO, INITIA
AL, APELLIDO)
ADDRESS/DIRECCIÓN
ADDRESS (IF
F DIFFERENT FROM PATIE
ENT) / DIRECCION
CITY/STATE/ZIP / CIUDAD/ESTADO/CODIGO
CITY/STATE//ZIP / CIUDAD/ESTADO/CO DIGO
HOME PHONE/NU
UMERO TELEFONO
DATE OF BIRTH/
MIENTO
FECHA DE NACIM
AGE/
EDAD
WORK PHONE
SEX/
SEXO
S
CELL PHONE/CELLU
ULAR
MAR
RRIED/SINGLE/TOGETHER
MAR
RIDO/SOLTERO/JUNTO
HOME PHON
NE/NUMERO TELEFONO
DATE OF BIR
RTH/
FECHA DE N
NACIMIENTO
AGE/
EDAD
WORK PHON
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SEX/
SEXO
CELL PHONE
MARRIED/SINGLE/TOGETH
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MARIDO/SOLTERO/JUNTO
EMERGENCY
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CONTACT
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INFO
ORMATION / CO
ONTACTO DE E
EMERGÉNCIA
CONTACT /CONT
TACTO DE EMERGENCIA
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ELATIONSHIP/RELACION
PATIE
ENT'S EMPLOYM
MENT/EMPLEAD
DO de PACIENTE
COMPANY NAME/COMPANIA
OCCUPATIO
ON/TRABAJO
DAY TIME PH
HONE/NUMERO TELEFONO
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ARTNER EMPL OYMENT/EMPL
LEADO de PARE
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COMPANY N
NAME/COMPANIA
ADDRESS/DIRECCION
ADDRESS/D
DIRECCION
CITY/STATE/ZIP / CIUDAD/ESTADO/CODIGO
CITY/STATE//ZIP / CIUDAD/ESTADO/CO DIGO
PRIMAR
RY OR PATIENT'S INSURANCE/Aseg
gurancia del Pacien
nte
INSURANCE
E COMPANY NAME/ASEGUR
RANCIA
P.O. BOX/ADDRESS / DIRECCION
P.O. BOX/AD
DDRESS / DIRECCION
CITY/STATE/ZIP / CIUDAD/ESTADO/CODIGO
CITY/STATE//ZIP / CIUDAD/ESTADO/CO DIGO
SUBSCRIBER NAME
GROUP NO./GRUPO
DO YOU HAVE FERTILIT
TY COVERAGE?
REFER
RRING PHYSICIA
AN/OTHER FOR
RM OF REFFERA
AL
OCCUPAT
TION/TRABAJO
SECO
ONDARY OR PAR
RTNER INSURANC
CE/Asegurancia de pareja
INSURANCE COM
MPANY NAME/ASEGURANC
CIA
POLICY I.D. NUMB
BER/NUMERO DE IDENTIFICACION
EVENING PHONE
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POLICY I.D. N
NUMBER/NUMERO DE IDE NTIFICACION
GROUP NO./GRUPO
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SUBSCRIBER
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OTH ER CONTACT IN
NFORMATION/O
OTRA INFORMA
ACIÓN
NAME /NOMBRE
Patient email address/Correo electronico d
de paciente:
ADDRESS/DIRECCION
Partner emaill address/Correo electronico de pareja:
CITY/STATE/ZIP / CIUDAD/ESTADO/CODIGO
Other/Otro:
PHONE/NUMERO
O DE TELEFONO
Your reccords are considered
d confidential inforrmation and we willl not release any infformation without yyour consent and siggnature. Please signn
the releaase below.
If needed, I hereby authorizze the Idaho Center for Reproductive Medicine
M
to release information to mysself, my insurance ccarrier, an
Independent audit agency or
o to my physician. I also authorize my
y insurance carrier tto reimburse the Idaaho Center for Reprroductive Medicinee
for serviices rendered.
DATE
E/FECHA __
___________
___ PATIENT
T/PACIENTE
E__________
_______________________
DATE
E/FECHA __
___________
___ PARTNE
ER/PAREJA____________
_______________________
HIPPA co
onsent (Initial Please) ________________
_
Revised 6/2008
Office form
m7
FEMALE PATIENT HISTORY
Date _______________
Name_____________________________________________________
Weight___________________ Height ____________________ Blood Type (if known) _________________
How long have you been trying to get pregnant?
Past history: (if applicable):
Year
Born Miscarriage? Abortion? Ectopic? Fert drugs Current Preterm
alive?
required? partner? labor?
Preterm How many Pregnancy-induced
delivery? weeks?
hypertension?
1st pregnancy __ ___ ______ ________ _______ ______ ________ ______ ______ ______ __________ __________
2nd pregnancy __ ___ ______ ________ _______ ______ ________ ______ ______ ______ __________ __________
3rd pregnancy __ ___ ______ ________ _______ ______ ________ ______ ______ ______ __________ __________
4th pregnancy __ ___ ______ ________ _______ ______ ________ ______ ______ ______ __________ __________
5th pregnancy __ ___ ______ ________ _______ ______ ________ ______ ______ ______ __________ __________
Has your partner ever fathered a child? (circle)
YES
NO
If yes, how many children/pregnancies?____________________________________________________
Infertility History:
Have you ever been treated for infertility?_________________________________________
If yes, have you used infertility medications (ie: follicle stimulation hormone-FSH or Clomid)? _________
How many cycles of medications? _______________________________________________________
Have you ever undergone an IVF cycle? (circle)
YES
NO
If yes, when and what were the results? _____________________________________________________
Menses:
When was the first day of your last period?
Are your periods regular?
If yes, how many days between periods?
Usual duration of menses?
If no, how many times per year do you menstruate?
Are your periods mild, moderate, severe, or none in terms of pain?
Is intercourse painful for you?
Do you have any issues with bowels during menses? (diarrhea, constipation, dumping syndrome)?
____________________________________________________________________________________
Have you ever used an ovulation predictor kit? (circle) YES
NO
If yes, when in your cycle do you have a positive surge? _________________________________________
Procedure History:
Have you had any pelvic surgery(ies) performed? (circle)
YES
NO
If yes, please explain: _____________________________________________________________________
D & C procedure(s)? YES NO If yes, how many and when? _____________________________________
Have you ever had a hysterosalpingogram (HSG) performed? (circle) YES
NO
If yes, who performed the HSG and what were the results? _______________________________________
Have you had a tubal ligation? YES NO
Have you been diagnosed with endometriosis? YES
NO
Please list all types and dates of surgeries you have undergone:___________________________________
______________________________________________________________________________________
Pap History:
When was your last pap smear done? ____________________Where? ____________________________
Was it normal or abnormal? ________________________
(office and physician name)
Have all of your paps been normal? (circle)
YES
NO
Have you had any lab work done? (If yes, please describe tests, results, and where performed):__________
_______________________________________________________________________________________
Medical History:
Are you currently experiencing any medical problems? (If yes, please describe):__________________________
__________________________________________________________________________________________
Family history of blood clotting disorders?
YES
NO
Anyone with cystic fibrosis in your family? (circle)
YES
NO
Have you ever been treated for cancer? (circle)
YES
NO
If yes, please explain: _____________________________________________________________________
C:\Users\cory.colt\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\LVR8VJ5V\Female History.doc
Do you currently have, or have you ever had (circle all that apply):
Anemia
Diabetes
Liver problems
Appendicitis
Dizziness
Loss of balance
Arthritis
Epilepsy
Measles: German
Bleeding disorder
Gall bladder problems
Measles: Regular
Blood transfusion
Gonorrhea
Mumps
Chlamydia
Heart disease
Mumps w/testes involved
Chronic bronchitis
Hepatitis
Neurological problems
Chronic headaches
Herpes
Nongonococcal urethritis
Colitis
High blood pressure
Parasitic infection
Cystic Fibrosis
Kidney infection
Pneumonia
Rheumatic fever
Scarlet fever
Seizures
Syphilis
Testes infection
Testes injury
Testes tumor
Thyroid problems
Tuberculosis
Visual disturbances
What medications do you regularly take? (Prescription and/or over the counter drugs; include dosage):_____________
_______________________________________________________________________________________________
What local pharmacy do you prefer?___________________________________________________________________
Do you currently or have you ever, used:
Alcohol? How many drinks per week?_______________________________________________
Cigarettes? How many packs per day?______________________________________________
Illicit or recreational drugs?________________________________________________________
Allergies? (circle) YES NO If yes, please list:_____________________________________________
Countries of origin:
Mother’s family:
Father’s family:
Ethnic background (circle):
African American
Jewish
Asian
American Indian
Ethnic Group:
(check all that apply)
Asian-Indian
Mediterranean
Have you ever been tested for:
African, African/American
Sickle cell trait
Chinese, Southeast Asian,
Mediterranean (Greek or
Italian) or Hispanic
Thalassemia
Caucasian, Jewish
Cystic Fibrosis
Jewish
Bloom Syndrome
Caucasian
Hispanic
Middle Eastern Other:________________
Yes
No
Date
Result
Canavan Familial
Dysautonomia (FD)
Fanconi Anemia (type C)
Gaucher Disease (Type I)
Glycogen Disease
(Type 1a)
Maple Syrup Urine
Disease
Mucolipidosis
(Type IV ML IV)
Niemann – Pick Type A
Spinal Muscular Atrophy (SMA)
_____________________________________________
Tay Sachs
Other inherited disorders?:
Would you like to take the test(s) recommended for your specific ethnic group? (Circle)
Are you related to your spouse (consanguinity)? (Circle)
YES
YES
NO
NO
Fragile X testing is recommended if the exact etiology of the mental retardation is unknown. Would you like this testing
performed? (Circle)
YES
NO
C:\Users\cory.colt\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\LVR8VJ5V\Female History.doc
MALE PATIENT HISTORY
Date _______________
Name_____________________________________________________
Weight___________________ Height ____________________ Blood Type (if known) _________
Have you fathered a pregnancy prior? (circle)
YES
NO
If yes, when and what was/were the outcome(s)? _____________________________________________
Are you, or have you ever been exposed to any of the following during employment or military service?
(If so, please explain)
Heat_______________________________ Toxic fumes_______________________________
Chemicals__________________________ Nuclear radiation___________________________
Other_________________________________________________________________________
Do you frequently take saunas or steam baths?
YES NO
Infertility History:
Have you ever been treated for infertility in the past?
YES
NO
If yes, please describe treatment: ___________________________________________________________
Have you had a vasectomy?
YES
NO
If yes, who performed the procedure? _______________________________________________________
Any history of pelvic infection? YES NO Pelvic trauma? YES NO Pelvic surgery? YES
NO
If yes, please explain: ____________________________________________________________________
Have you ever had a semen analysis? (If yes, who performed the test and what were the results?)
______________________________________________________________________________________
Procedure History:
Please list all types and dates of surgeries you have undergone:___________________________________
______________________________________________________________________________________
Medical History:
Are you currently experiencing any medical problems? (If yes, please describe):_______________________
______________________________________________________________________________________
Have you ever been treated for cancer?
YES
NO
If yes, please explain: ____________________________________________________________________
What medications do you regularly take? (Prescription and/or over the counter drugs; include dosage)
_____________________________________________________________________________________
_____________________________________________________________________________________
Allergies?
YES NO
If yes, please list:________________________________________________________________________
Family history of blood clotting disorders? YES NO
Any other medical problems in the family? YES
NO
If yes, please explain? _____________________________________________________________________
Do you, or have you ever, had (circle all that apply):
Anemia
Diabetes
Liver problems
Rheumatic fever
Appendicitis
Dizziness
Loss of balance
Scarlet fever
Arthritis
Epilepsy
Measles: German
Seizures
Bleeding disorder
Gall bladder problems Measles: Regular
Syphilis
Blood transfusion
Gonorrhea
Mumps
Testes infection
Chlamydia
Heart disease
Mumps w/testes involved
Testes injury
Chronic bronchitis
Hepatitis
Neurological problems
Testes tumor
Chronic headaches
Herpes
Nongonococcal urethritis
Thyroid problems
Colitis
High blood pressure
Parasitic infection
Tuberculosis
Cystic Fibrosis
Kidney infection
Pneumonia
Visual disturbances
Cancer (specify)___________________________
Prostatitis
Do you or have you ever, used:
Alcohol? How many drinks per week?___________________
Cigarettes? How many packs per day?___________________
Illicit or recreational drugs?________________________________________________________
C:\Temp\ICRM\Male History.DOC
Countries of origin:
Mother’s family:
Father’s family:
Ethnic background (circle):
African American
Jewish
Asian
American Indian
Ethnic Group:
(check all that apply)
Asian-Indian
Mediterranean
Have you ever been tested for:
African, African/American
Sickle cell trait
Chinese, Southeast Asian,
Mediterranean (Greek or
Italian) or Hispanic
Thalassemia
Caucasian, Jewish
Cystic Fibrosis
Jewish
Bloom Syndrome
Caucasian
Middle Eastern
Yes
No
Hispanic
Other:________________
Date
Result
Canavan Familial
Dysautonomia (FD)
Fanconi Anemia (type C)
Gaucher Disease (Type I)
Glycogen Disease
(Type 1a)
Maple Syrup Urine
Disease
Mucolipidosis
(Type IV ML IV)
Niemann – Pick Type A
Spinal Muscular Atrophy (SMA)
Tay Sachs
Other inherited disorders?:
Would you like to take the test(s) recommended for your specific ethnic group? (Circle)
Are you related to your spouse (consanguinity)? (Circle)
YES
YES
NO
NO
Fragile X testing is recommended if the exact etiology of the mental retardation is unknown. Would you like this testing
performed?
(Circle)
YES
NO
C:\Temp\ICRM\Male History.DOC
Idaho Center for Reproductive Medicine
111 Main Street Suite # 100 / Boise, ID 83702 / (208) 342-5900
ICRM Notice of Privacy & Security Practices
This following information explains how your personal health information might be
used or disclosed and how you can attain access to this information. Please review
this information carefully.
Uses and Disclosures
Medical Action: Your information may be used by ICRM or disclosed to other health
care professionals for the purpose of evaluation your health, diagnosing medical
conditions, and providing treatment. For example, results of laboratory tests and
procedures will be available in your medical record to all health professionals who may
provide treatment or who may be consulted by staff members.
Health Care Operations: Your protected health information may be used as necessary to
support the day-to-day activities and management of ICRM. For example, information
on the services you received may be used to support budgeting and financial reporting,
and activities to evaluate and promote quality.
Payment: Your health information may be used to seek payment from your health plan,
from other sources of coverage such as credit card companies that you may use to pay for
services. For example, your health plan may request and receive information on dates of
service, the services provided, and the medical condition being treated.
Law Enforcement Officials: Your health information may be disclosed to law
enforcement agencies, without your permission, to support government audits and
inspections, to facilitate law-enforcement investigations, and to comply with government
mandated reporting.
Public Health Reporting and Officials: Your health information may be disclosed to
public health agencies as required by law. For example, we are required to report certain
communicable diseases to the state’s public health department. Other uses and
disclosures require authorization. Disclosure of your health information or its use for any
purpose other than those listed above requires your specific written authorization. If you
change your mind after authorizing a use or disclosure of your information you may
submit a written revocation of the authorization. However, your decision to revoke the
authorization will not affect or undo any use or disclosure of information that occurred
before you notified us of your decision.
Additional Uses of Information
Appointment reminders. Your health information may be used by our staff to send you
appointment reminders.
Individual Rights
You have certain rights under the federal privacy standards. These include:

The right to request restrictions on the use and disclosure of your protected health
information.





The right to receive confidential communications concerning your medical
condition and treatment.
The right to inspect and copy your protected health information.
The right to amend or submit corrections to your protected health information.
The right to receive an accounting of how and to whom your protected health
information has been disclosed.
The right to receive a printed copy of this notice.
Use and Disclosure of Your Protected Health Information
Your protected health information will be used by ICRM or disclosed to others for the
purposes of treatment, obtaining payment, or supporting the day-to-day health care
operations of the practice.
Notice of Privacy Practices
You can read the ICRM Security and Privacy Policy for a more complete description of
how your protected health information may be used or disclosed. You may review the
policy prior to signing this consent.
Requesting a Restriction on the Use or Disclosure of Your Information
You may request a restriction on the use or disclosure of your protected health
information. ICRM may or may not agree to restrict the use or disclosure of your
protected health information. If ICRM agrees to your request, the restrictions will be
binding on the practice.
Cancellation of Consent
You may abrogate this consent to the use and disclosure of your protected health
information. You must cancel this consent in writing. Any use or disclosure that has
already occurred prior to the date on which your cancellation of consent is received will
not be affected.
Reservation of Right to Change Privacy Practices
ICRM reserves the right to modify the practices outlined in the notice.
I have reviewed this HIPAA consent form and give my permission to ICRM to use and
disclose my health information in accordance with it.
___________________________
Name of patient (print)
____________________________
Patient signature
____________
Date
___________________________
Name of partner (print)
____________________________
Partner signature
____________
Date
___________________________
Name of patient representative
____________________________
Patient representative signature
____________
Date
___________________________
Relationship to patient
Revised 6/08
Office form 12
Idaho Center for Reproductive Medicine
111 Main Street Suite # 100 / Boise, ID 83702 / (208) 342-5900
Request for Confidential Communication of Protected Health Information
I, ____________________________ give ICRM permission to disclose medical
(Patient’s Name - Please Print)
information and/or test results to ______________________________________.
Please list the relationship to the patient: ________________________________.
____________________________
(Patient’s Signature)
_________________
(Date)
I, ____________________________ give ICRM permission to disclose medical
(Patient’s Name - Please Print)
information and/or test results to ______________________________________.
Please list the relationship to the patient: ________________________________.
____________________________
(Patient’s Signature)
Revised 6/2008
_________________
(Date)
Office form 5
Patient-ICRM Electronic Communication Agreement
Electronic communications, including, but not limited to, emails, internet-based video conferencing through such applications
as Skype and “FaceTime” through iPhones and iPads, for example (hereinafter “Electronic Communications”) provide an
opportunity to communicate with your healthcare provider relative to issues that are non-emergent, non-urgent or noncritical. Electronic Communications are not a replacement for the interpersonal contact that is the very basis of the doctorpatient relationship.
The following is intended to assist you with your determination of whether you wish to supplement your healthcare experience
by electronically communicating with members of the healthcare team at the Idaho Center for Reproductive Medicine (ICRM,
“Healthcare Provider”).
General Considerations
 Your Healthcare Provider will treat Electronic Communications with the same degree of privacy and confidentiality as
written medical records. Your Healthcare Provider has taken reasonable steps with internal information technology
systems to protect the security and privacy of your personal identifying and health information in accordance with the
security guidelines required by the Health Information Protection and Accountability Act of 1992, as amended (HIPAA.)
 Standard email services, including, but not limited to, AOL, Optonline, Hotmail, and Gmail, are not secure. This means
that the email messages are not encrypted and can be intercepted and read by unauthorized individuals.
 Electronic communication via internet based video conference providers, including, but not limited to, Skype, claim to
have safeguards in place to protect your personal information from unauthorized disclosure. However, there is the
possibility that viruses, Trojans or other malicious software may obtain your private information on your computer system
and release and/or use your information without your knowledge. There may be other risks associated with internet
communication which are unknown at this time.
 Transmitting email that contains protected health information through an email system that is not encrypted do not meet
and electronic communication via internet based video conference providers may not meet the security guidelines as
required by the HIPAA.
I have read and understood the above description of the risks and responsibilities associated with Electronic
Communications with Healthcare Provider. I acknowledge that commonly used Electronic Communications are not
secure and fall outside of the security requirements set forth by HIPAA.
I understand that I can withdraw this consent authorizing Healthcare Provider to communicate with me via Electronic
Communications at any time by written notification to Healthcare Provider.
I release and hold harmless Healthcare Provider, its physicians and their staff, employees, affiliates, agents, officers,
directors and shareholders from any and all expenses, claims, actions, liabilities, attorney fees, damages, losses, of any
kind that I may have resulting from Electronic Communications between Healthcare Provider and me based on this
authorization given to Healthcare Provider to communicate with me via Electronic Communications.
Having been informed of the risks associated with Electronic Communications, I still desire to communicate with
Healthcare Provider via electronic communications. In consideration for my desire to use Electronic Communications
as an adjunct to in-person office visits with Healthcare Provider, I hereby authorize ICRM staff to engage in Electronic
Communication with me.
________________________________________________ _________________
Patient Signature
Date
________________________________________________ _________________
Partner Signature
Date
BILLING OFFICE POLICIES
Idaho Center for Reproductive Medicine
We look forward to providing you the most cost-effective treatments available to achieve your dream of
parenthood. In order to keep our services as affordable as possible, we ask that you proactively follow
our billing policies.
The average cost of a new patient appointment is $230, with possible additional charges. It is imperative
that we have a current copy of your insurance card on file, so please bring this with you to all
appointments. As a service, we will bill participating contracted insurance carriers for covered services.
Non-covered services are to be paid at the time of service. We will do our best to inform you whether
benefits are or are not covered, but bear in mind these quotes are only from experience and cannot
guarantee what your insurance will allow. Every employer determines what benefits they want to make
available to their employees. We recommend you call your insurance carrier directly to get your
current benefits, asking the following questions:
1) Do I need a referral from my primary care physician to obtain a consultation or service
from Dr. Slater or Dr. Foulk?
2) Are diagnostic infertility tests covered? (Exampls – AMH (Anti-Mullerian hormone blood
test), hysterosalpingogram (HSG), semen analysis, etc.)
3) Is treatment for infertility covered? (Examples – intrauterine inseminations, in vitro
Fertilization (IVF))
If your insurance carrier requires a referral, please make sure you have the appropriate referral BEFORE
you seek care from our office. You are responsible for keeping track of the number of visits used and/or
expiration date on your referral. If you do not obtain the necessary referrals, no benefits will be paid by
your insurance and you will be responsible in full for the services rendered. Insurance carriers will not
back date referrals, so make sure you have the referral prior to seeking care.
Please realize that insurance carriers have the right to request your medical records at any time. You gave
them that right when you signed up with them. This office will not participate in any form of insurance
fraud. Also realize that the law of limits allows your insurance carrier to audit your claims for up to seven
years after the date of service and to ask for all money paid incorrectly to be refunded back to the
insurance carrier.
Our business policies are a necessary part of the financial resources required to maintain this vital health
care service for our patients. If you have disputes with your insurance carrier, you, the insured will get a
quicker and more accurate response than our office. Please understand your insurance coverage is a
contract between you and your insurance company and while we will continue to provide this service, you
are ultimately responsible for your account.
I acknowledge that I have read, understand, and agree to abide by the above information.
____________________________________________
(Signature)
_________________
(Date)
____________________________________________
(Signature/Partner)
_________________
(Date)
Idaho Center for Reproductive Medicine
Russell A. Foulk, M.D.
Reproductive Endocrinology & Fertility
Laboratory Director
Cristin C. Slater, M.D.
Reproductive Endocrinology & Fertility
Medical Director
111 Main Street Suite # 100
Boise, Idaho 83702
Phone # (208) 342-5900
Fax # (208) 342-2088
Authorization to Release Medical Records
Patient Name(s):___________________________________________________________________________
Date(s) of Birth:______________________________ Phone #(s):___________________________________
FROM: _________________________________________________________________________________
___________________________________ Fax #__________________________________________
___________________________________ Phone #_______________________________________
TO:
_________________________________________________________________________________
___________________________________ Fax #_________________________________________
___________________________________ Phone #_______________________________________
I hereby authorize and request the release of the following information:
______ All Medical Records
______ Medical record information for visit date of __________ to __________.
______ Progress Notes
______ Lab reports
______ Hospital and/or Operative reports
______ Other: ____________________________________________________________________________
I understand that my records may contain information regarding the diagnosis or treatment of HIV (AIDS virus), other sexually transmitted diseases,
drug and/or alcohol abuse, mental illness or psychiatric treatment, and infertility treatment. I give authorization for these records to be released.
This authorization is valid for this request only. This authorization may be revoked in writing at any time with the exception of information released
prior to the date of the written revocation. The Idaho Center for Reproductive Medicine cannot condition treatment or eligibility of benefits on
whether the authorization is signed. Protected health information (PHI), once released, has the potential to be redisclosed by the recipient and is no
longer protected by the Idaho Center for Reproductive Medicine.
Signature (patient): __________________________________________ Date: ______________________
Signature(partner):___________________________________________ Date:______________________
Russell A. Foulk, M.D.
Cristin C. Slater, M.D.
Reproductive Endocrinology & Fertility
111 Main St., Suite 100
Boise, Idaho 83702
Tel.(208) 342-5900
Fax (208) 342-2088
Idaho Center
for Reproductive
Medicine
Genetic Carrier Screening Recommendations
The American College of Obstetricians and Gynecologist (‘ACOG’) and the American College of Medical Geneticists and Genomics
(‘ACMG’) recommends genetic carrier screening tests for patients who are planning a pregnancy to screen for genetic disorders for
which you may be a carrier. A carrier is someone that has a single abnormal gene that may be passed to the child. If you pass the
abnormal gene to the child, the child will be a carrier for that genetic disease. However, if your reproductive partner also carries the
same abnormal gene, there is a 25% chance that your child will inherit one abnormal gene from each parent and be affected with that
genetic disease. Most genetic disorders are diseases that have serious ongoing medical problems and are associated with a shorter life
span.
Cystic Fibrosis (‘CF’) and Spinal Muscular Atrophy (‘SMA’) are two genetic carrier screening tests recommended for all patients,
regardless of medical/family history or ethnicity, due to the prevalence of these genetic carrier conditions in the general population.
Other genetic carrier tests are recommended based on a person’s ethnic or racial background and/or family history. The selection of
these tests is consistent with the recommendations from ACOG and ACMG for genetic carrier screening based on current evidence of
their prevalence in certain ethnic and racial populations.
The recommended genetic carrier screening tests can be expensive and may or may not be covered by medical insurance. Keep in
mind that if you test positive for any of the genetic conditions, your reproductive partner will need to be tested. You will have the
opportunity to meet with one of our financial counselors to discuss the cost of the specific tests recommended for you.
The following is a list of recommended genetic carrier screening tests by ethnicity. Please check the boxes next to any/all ethnic
groups with which you and your partner identify below (if applicable):
Genetic Disease
Cystic Fibrosis (Panel 1 & 2)
Spinal Muscular Atrophy
(Panel 1 & 2)
Beta Thalassemia (Panel 2)
Bloom Syndrome (Panel 2)
Canavan Disease (Panel 2)
Familial Dysautonomia (Panel
2)
Fanconi’s Anemia Type C
(Panel 2)
Guacher’s Disease (Panel 2)
Hexosaminidase A Deficiency
(Panel 2)
Mucolipidosis Type IV (Panel
2)
Niemann-Pick Disease Type A
(Panel 2)
Sickle Cell Disease (Panel 2)
Tay-Sachs (Panel 2)
Hemoglobinopathy Profile
(Not included in Panel 1 or 2)
Female
Ethnicity
Male
All patients
All patients
African, African American, Cajun, Eastern Asia, French Canadian, Hispanic,
Middle Eastern, Northwest European, South Asia, Southeast Asia, Southern Europe
Ashkenazi Jewish
Ashkenazi Jewish
Ashkenazi Jewish
Ashkenazi Jewish
Ashkenazi Jewish
Ashkenazi Jewish
Ashkenazi Jewish
Ashkenazi Jewish
African, African American,
Ashkenazi Jewish, Cajun, French Canadian
African, African American, Caribbean, Central American, Hispanic, Latin
Mexican, Middle Eastern, Northwestern European, Puerto Rican, South Asia,
Southeast Asia, Southern Europe
Genetic carrier testing is recommended but not required prior to fertility treatment. However, you cannot proceed with fertility
treatment until you have made a decision regarding genetic carrier testing. If screening is accepted and the results have been returned
indicating that genetic carrier screening for your reproductive partner is indicated you will need to complete the recommended
screening or sign a consent declined the recommended screening prior to treatment. For information about specific genetic disorders,
please visit www.counsyl.com.
Clinical form 256 Idaho Center for Reproductive Medicine
111 Main St. Ste. 100 / Boise, ID 83702 / (208)342-5900
ICRM Genetic Screening Fee Schedule
ICRM Fundamental Panel (Panel 1)
(Cystic Fibrosis-32 mutations)
$349.00
ICRM Counsyl Panel (Panel 2)
(Cystic Fibrosis-32 mutations)
$349.00
Cystic Fibrosis- 97 mutations
Lab Corp
$340.00
Fragile X
Lab Corp
$305.00
Karyotype
State lab
$707.00
Hemoglobinopathy Panel
Lab Corp
$50.00
clinical form 257
Russell A. Foulk, M.D.
Cristin C. Slater, M.D.
Reproductive Endocrinology & Fertility
111 Main St., Suite 100
Boise, Idaho 83702
Tel.(208) 342-5900
Fax (208) 342-2088
Idaho Center
for Reproductive
Medicine
Genetic Carrier Screening Consent
Genetic carrier screening is done to determine if one or both parents may have abnormal genes that may increase the chance that their
child will have a specific genetic disease. For many genetic diseases, if someone has an abnormal gene, that person is considered a
carrier for that genetic disease. If this abnormal gene is passed to the child, the child will usually not be affected with that genetic
disease but will be a carrier for that genetic disease. If both parents are carriers of the abnormal gene for the same genetic disease,
there is a 25% chance that their child will inherit one abnormal gene from each parent and be affected with that genetic disease.
Genetic screening is typically done on one partner first, and if the first partner tests positive, then the other reproductive partner is
tested.
The American College of Obstetricians and Gynecologists (‘ACOG’) and the American College of Medical Geneticists and Genomics
(‘ACMG’) recommend routine screening for certain genetic diseases and additional screening when indicated due to ethnicity, family
history, or other known risk factors. Two of the recommended standard genetic carrier screening tests include Cystic Fibrosis (‘CF’)
and Spinal Muscular Atrophy (‘SMA’).
During the course of your evaluation and treatment at ICRM, your physician may recommend additional genetic carrier screening for
specific genetic disease(s) which may be indicated based on your medical history and/or family history to determine whether or not
you are a carrier for the specified genetic disease(s). Also, there are certain genetic carrier screening tests that may be ordered by your
physician based on your ethnic or racial background.
Although genetic carrier screening tests are a valuable tool there are limitations:
 Negative result – The genetic testing laboratory usually tests for the most common mutations (change in gene structure) and
may not identify the less common mutations. So it is possible to have a negative test result but still have a genetic mutation
that was not or could not be identified by the testing laboratory due to limitations of current technology.
 Positive result - A positive test result indicates that you are a carrier for a genetic mutation that can cause a specific genetic
disease or can put you and/or your child at risk for developing a disease. If you are determined to be a carrier, your
reproductive partner will then be advised to undergo genetic carrier testing.
 Inconclusive result – Sometimes it is not possible for the testing laboratory to determine genetic mutations. In this case, the
genetic carrier test may need to be performed again at the same or different testing laboratory.
It may take 2 to 3 weeks to receive the genetic carrier screening test results and testing should be performed prior to beginning fertility
treatment. Additionally, if you are concerned with passing an inherited (genetic) disorder to your offspring, you have the option of
speaking with a genetic counselor, who may suggest additional preconception tests or post-conception (prenatal) procedures such as
amniocentesis.
I/We acknowledge:
 The genetic carrier screening tests that have been recommended to me are voluntary and if I choose to have them performed,
it will be to determine if I am a genetic carrier (within the limitations of the test) of the conditions being tested.
 Fertility treatment cannot proceed until I/we have made a decision regarding genetic carrier screening and, if genetic carrier
screening is not declined, the genetic carrier screen results are returned indicating genetic carrier screening for my
reproductive partner is not indicated.
 The importance of genetic counseling to further discuss the genetic test(s) and how it may affect me and my family.
Information about genetic counseling services has been provided to me.
 The cost of the recommended testing may not be covered by my insurance plan and I will be responsible for the costs
associated with the genetic carrier testing.
 It may be possible that even with a negative result I still could be a genetic carrier or predisposed to the genetic condition
being tested due to the limitations of the genetic testing.
Clinical form 254
1




The genetic test results will be contained in my medical record and the Center will take all appropriate safeguards to protect
the confidentiality of my personal health information. However, I hereby consent to the release of these results to my
partner, the physicians and nursing staff directly involved in my care for the purpose of my treatment, my current insurance
carrier in order to seek coverage or reimbursement, and others specifically authorized by law to gain access to my medical
records.
Current Federal & State laws prohibit discrimination by insurance carriers based on results of genetic carrier screening tests.
I will release my genetic carrier screening test results to my partner. It has been recommended that I discuss the results of my
genetic carrier screening test with family members.
The recommended testing should be performed and results should be reviewed prior to initiating any fertility treatment.
Proceeding with fertility treatment without the benefit of my genetic carrier status could results in an unfavorable outcome
including a child with a genetic disorder.
ACKNOWLEDGEMENT
I/We have met with my/our physician and healthcare team to discuss genetic carrier screening. I/We have been fully informed of the
purpose of the genetic carrier screening, reliability of the screening results, risks and benefits of agreeing to or declining genetic
carrier screening and/or genetic counseling and available alternatives to genetic carrier screening. I/We have had the opportunity to
ask questions and have all my/our all my questions answered to my/our satisfaction.
I/We have made the following decision regarding genetic carrier screening, free from coercion:
_____
______ I/We consent to genetic screening and elect:
_____
_____
_____
_____
_____
______ ICRM Fundamental Panel
______ ICRM selected Counsyl Panel
______ Counsyl Full Panel
______ Fragile X
______ Hemoglobinopathy Panel
_____
______ I/We have already had genetic screening prior to coming to ICRM
_____
______ I/We decline genetic screening and understand that this is against the advice of ICRM physicians. I/We agree to
hold ICRM, its physicians, agents and staff harmless from any and all liability should any consequences occur
secondary to my declination of genetic carrier screening.
_____
______ I/We would like more information about genetic carrier screening from a genetic counselor before making a
decision. I/We understand that fertility treatment cannot proceed until I/we have made a decision to consent to or
decline genetic carrier screening and have signed and dated the informed consent form, and, if the genetic carrier
screening has not been declined, the genetic carrier screening results have been returned indicating that genetic
carrier screening for my reproductive partner is not indicated.
________________________________
Name-Female Patient (Please print)
________________________________
Name-Reproductive Partner (Please print)
________________________________
Signature- Female Patient
________________________________
Signature – Reproductive Partner
____________________
Date
_________________
Date
Clinical form 254
2
Sp
pinal Muscu
M
ular Attrophy
y
Wha
at is Spinal Muscular Atrophy?
A
Spina
al muscular atro
ophy (SMA) is a disease in which
w
certain ne
erves in the bra
ain and spinal ccord die, impairring the person
n’s ability to
move
e. Called motorr neurons, thes
se nerves contrrol our ability to
o sit up, crawl, and walk. In se
evere cases, a person will no
ot be able to sit
up ind
dependently an
nd their breathing and swallow
wing may also be impaired. In
n the mildest ca
ases, symptom
ms begin in adu
ulthood and
make
e independent movement
m
such as walking more
m
difficult, bu
ut still possible . There are five
e main subtype
es of spinal muscular atrophy,
each described belo
ow. It is not alw
ways possible to
o predict which
h type of SMA a child could ha
ave based on tthe genetic mutation he or
she in
nherits. This is true of the muttation (exon 7 deletion)
d
for wh
hich Counsyl te
ests.
Type
e0
Type 0 is the most severe
s
form of SMA. Symptom
ms can often be seen in the la
ater stages of p
pregnancy as tthe fetus is lesss active than
expeccted. Once borrn, the infant wiill have little ab
bility to move an
nd may not be able to breathe
e and swallow independentlyy. Infants with
type 0 SMA often die before the ag
ge of 6 months
s.
Type
e I – Also Callled Werdnig
g-Hoffmann Disease
D
Type I is another se
evere form of th
he disease. Sym
mptoms develo
op within the firrst six months o
of life. Infants w
with SMA type I often have
troublle breathing an
nd swallowing. Their muscle tone and streng
gth are extreme
ely poor; they ccannot sit up w
without support and will not
meet any motor skills milestones. Their intellect, however, is no
ormal. Most ch
hildren with typ
pe I SMA will diie before the ag
ge of two.
Type
e II – Also Ca
alled Dubowitz Disease
In children with type
e II SMA, muscle weakness be
ecomes appare
ent between th
he ages of 6 an
nd 12 months. W
When placed in
n a sitting
position, people with
h type II SMA can
c usually maintain the posittion without sup
pport, howeverr they often losse this ability byy their midteenss. People with SMA
S
type II can
nnot stand or walk
w
without as
ssistance. Theyy have poor mu
uscle tone and strength and th
heir fingers
usually tremble unco
ontrollably. Th
heir intelligence
e is typically normal or above average.
Type
e III – Also Ca
alled Kugelb
berg-Welande
er Disease
Type III SMA is a milder form of the disease. Its symptoms
s
begin sometime be
etween the age
e of one year a
and early adulth
hood. As young
g
childrren, they may fall repeatedly and
a have troub
ble walking dow
wn stairs. While
e their muscless are weaker th
han normal, peo
ople with type
III SM
MA can usually stand and walk without assis
stance, although they may losse this ability la
ater in life. The legs are often more severely
affectted than the arm
ms.
Type
e IV
Type IV is the milde
est form of spinal muscular atrrophy. With this
s form of the diisease, muscle
e weakness does not begin until one’s 20s
or 30ss, or even laterr. This weakness is often mild
d to moderate, and the person
n can still walk and move inde
ependently. Th
hese individuals
s
may e
experience mild
d to moderate tremors and/orr twitching. The
e disease typica
ally does not d
diminish lifespan. With all type
es of SMA,
there can be difficultties in sleeping
g and gaining weight.
w
Frequen
nt pneumonia iis common. A ccurvature of the
e spine and stiff joints are
also ccommon. Wom
men with milder forms the dise
ease have been
n known to give
e birth to health
hy children, although many off the
pregn
nancies had complications.Th
he disease is ca
aused by a sho
ortage in SMN protein, which helps preserve
e motor neuron
ns. Without it,
the ne
eurons cannot pass message
es from the brain to the musclles of the bodyy.
How
w Common is
i Spinal Mu
uscular Atrophy?
In the
e United States
s, 1 in every 6,0
000 to 10,000 people
p
develop
p spinal muscullar atrophy and
d 1 in 50 is a ca
arrier of the dissease. It has
been found in peoplle of every race
e, but is most common
c
in Cau
ucasians, of wh
hom 1 in 35 is a carrier. Carrie
er rates for oth
her populations
includ
de: Ashkenazi Jews
J
(1 in 41 to 62), Asians (1
( in 53), Africa
an Americans ( 1 in 66), and H
Hispanics (1 in 117). Studies d
done in specific
c
popullations have found carrier rate
es of 1 in 50 in Germany, 1 in
n 57 in Italy, an
nd 1 in 62 in Ch
hina.
How
w is Spinal Muscular
M
Attrophy Trea
ated?
There
e is no cure for spinal muscula
ar atrophy, how
wever some of its symptoms ccan be addresssed. For childre
en with the mo
ore severe
formss of spinal muscular atrophy, mechanical bre
eathing aids ma
ay prolong lifesspan. In some cases, breathing is more diffiicult at night,
leading to a lack of sleep. In those cases, certain types of respiratory assistance may be helpful. If getting enough nutrition is an issue,
some people with SMA have turned to feeding tubes.
Those with milder forms of the disease sometimes choose to have surgery to correct curvature of the spine (scoliosis) or joint problems.
In forms of the diseases that are fatal in early childhood, these surgeries are often not done.
What is the Prognosis for a Person With Spinal Muscular Atrophy?
The prognosis for a person with SMA varies greatly depending on which type of the disease he or she has.
Type 0
The disease is typically fatal between 2 and 6 months of age. These infants do not develop any motor skills expected of infants their
age.
Type I
This type of SMA is usually fatal within two years. With mechanical breathing aids, children with type I SMA may live longer. There are
a few known cases of SMA type I in which the child survived to adolescence or adulthood.
Type II
With type II SMA, 75% of those affected live to the age of 25. They are often able to sit independently when placed in a sitting position,
but lose this ability by their mid-teens.
Type III
People with type III SMA may live a normal lifespan. Many learn to walk independently, though most lose the ability to do so by their
30s or 40s.
Type IV
A normal lifespan is possible for people with type IV SMA. They do not develop symptoms until their 20s or 30s and usually retain the
ability to walk independently.
Resources
Claire Altman Heine Foundation
While other organizations are working hard to find a treatment or cure, the Claire Altman Heine Foundation uses its funding to identify
carriers of SMA, support population based SMA carrier screening, raise awareness of SMA and educate the public and medical
communities about SMA.
1112 Montana Avenue # 372
Santa Monica, CA 90403
Phone: (310) 260-3262
[email protected]
Families of SMA
A group of 55,000 members that aims to advance research on SMA and support families affected by it.
P.O. Box 196
Libertyville, IL 60048-0196
Phone: (800) 886-1762
[email protected]
Genetics Home Reference
Explanations of an extensive number of genetic diseases written for everyday people by the U.S. government's National Institutes of
Health.
Cy
ystic Fibros
F
sis
What is Cysttic Fibros
sis?
Cystiic fibrosis (CF
F) is a genetic
c condition ch
haracterized by
b the producttion of abnorm
mally thick, stticky mucus, p
particularly in
the lu
ungs and dige
estive system
m. While it is normal to have
e mucus lining
g the organs of the respira
atory, digestivve, and
repro
oductive syste
ems in order to
t lubricate an
nd protect the
em, in people with CF this mucus is thicck and sticky. This
abno
ormal mucus results
r
in the clogging and obstructing of
o various sysstems in the b
body. CF is a chronic condition that
worsens over time
e.
Mostt people with CF experienc
ce breathing problems
p
and frequent lung
g infections th
hat lead to pe
ermanent lung
g damage
such as scarring (fibrosis)
(
and sac-like grow
wths (cysts). The
T pancreas , an organ tha
at produces in
nsulin and dig
gestive
enzyymes, is often affected by CF.
C The sticky
y mucus caus
sed by CF can
n block ductss which ferry e
enzymes from
m the
panccreas to the re
est of the body, resulting in
n problems su
uch as diarrhe
ea, malnutritio
on, and poor g
growth. Inferttility,
particcularly in men
n, and delayed puberty are
e also commo
on among peo
ople with cysttic fibrosis.
The sseverity of symptoms varie
es from perso
on to person. Most cases o
of CF are diag
gnosed in earrly childhood. Those who
are d
diagnosed afte
er the age of 18 typically have
h
a milder form of the co
ondition.
Muta
ations in the same gene tha
at causes CF can result in a condition in
n males called congenital absence of th
he vas
deferrens (CAVD). In CAVD, the
e vas deferen
ns (a reproduc
ctive organ in
nvolved in spe
erm transport) is improperly formed,
leading to infertility
y.
How
w Commo
on is Cysttic Fibros
sis?
Acco
ording to the National
N
Institutes of Health
h, CF is the most
m
common
n deadly inherrited condition
n among Cau
ucasians in
the U
United States.. Disease-cau
using mutation
ns in the CFT
TR gene are m
more common
n in some eth
hnic populations than
otherrs.
Ethn
nic Group
Carrier Ra
ate
Affecte
ed Rate
Cauccasian
1 in 28
1 in 3,0
000
Ashkkenazi Jewish
h
1 in 28
1 in 3,0
000
Hispa
anic
1 in 46
1 in 8,3
300
Africa
an American
1 in 66
1 in 17,000
Asian
n
1 in 87
1 in 30,000
How
w is Cystiic Fibrosis Treated
d?
There
e is no treatm
ment that addrresses the ca
ause of CF, bu
ut there are m
many options to treat the syymptoms it prroduces.
Beca
ause thick mucus can build
d up in the res
spiratory syste
em, it is impo
ortant to keep the person's airways open
n in order to
ease
e breathing an
nd prevent infe
ection. This can
c be accom
mplished with vvarious presccription drugs as well as byy physically
loose
ening mucus by pounding on
o the person
n's back in a prescribed
p
wa
ay. This treatm
ment, known as "postural d
drainage and
chest percussion" must be perfformed by som
meone other than the affeccted person, and is typicallly done at lea
ast once daily
y.
As re
espiratory infe
ections occur,, physicians ty
ypically presc
cribe antibioticcs.
Physicians will also monitor the digestive system to ensure that the person is getting proper nutrition. Enzymes or vitamin
supplements may be prescribed. Both the respiratory and digestive systems of a person with CF must be monitored
regularly by his or her medical team.
Surgery may be needed to correct certain problems caused by CF. Lung transplants are an option for some people.
What is the Prognosis for a Person With Cystic Fibrosis?
Thanks to improved treatments and a better understanding of the condition, the average life expectancy for people with
CF who live to adulthood is 35 years. Children born with CF today who receive early treatment may live even longer.
Resources
Cystic Fibrosis Foundation
The largest non-profit devoted to CF, it has 80 chapters and branches across the U.S. It funds research on CF, accredits
CF care centers, and provides families with support and information.
6931 Arlington Road
Bethesda, MD 20814
Phone: (800) FIGHT-CF (344-4823)
[email protected]
Genetics Home Reference
Explanations of an extensive number of genetic conditions written for everyday people by the U.S. government's National
Institutes of Health.
National Heart Lung and Blood Institute
A division of the government-run National Institutes of Health, NHLBI maintains a straightforward site with facts about CF.
NHLBI Health Information Center
P.O. Box 30105
Bethesda, MD 20824-0105
Phone: (301) 592-8573
[email protected]
Other Names for Cystic Fibrosis





Fibrocystic Disease of Pancreas
Cystic Fibrosis
CFTR-Related Disorders
CF
Mucoviscidosis