Pioneers in Reproductive Medicine and Genetics

Payment Authorization Form

SECTION A: PATIENT INFORMATION
Patient Last Name: ____________________________ First:_______________________ Middle: ______________ DOB:___________________
Partner Last Name: ____________________________ First:_______________________ Middle: ___________ DOB:______________________
Patient Street Address: ______________________________________________________________________________________________
City: __________________________________________ State:________________________________________ Zip Code: ____________________
Home#: ______________________________ Work#: _________________________________ Other#: _____________________________
Email address (optional): ____________________________________________________________________________________________
Name of IVF Clinic: ____________________________________________________________________________________________
Referring Physician: ____________________________________________________________________________________________

SECTION B: PAYMENT OPTIONS

If you are sending a personal check, money order or cashier’s check please mail your check along with the forms to: Igenomix USA •
7955 NW 12th Street, Suite 415 • MIAMI, Florida • 33126 • United States.

• Credit card1: Visa Mastercard AMEX Discover Card Number: _____________________________________

CVV2 Code (3 or 4 digit security code): ______________________________ Expiration date: ________________________________
Cardholder Name: _______________________________________________________________________________________________
Cardholder Street Address (if different from above): ______________________________________________________________________
City: __________________________________________ State:________________________________________ Zip Code:____________________
By signing below I authorize Igenomix USA to charge my credit card the total fee on the attached invoice.

Cardholder signature: _______________________________________________________________________ Date: ____________________

• E-Check Authorization2: IGenomix does not accept E-Checks.

SECTION C: PAYMENT OPTIONS / Bank Transfer

JP Morgan Chase
Routing: 322271627
ABA: 021000021
Swift: Chasus33
Account# 212521539

SECTION D: FINANCIAL CONSENT

By signing this form, I have read and agree to the Financial terms and policy detailed below, I fully understand these charges and I am
responsible for the total payment of all testing performed by Igenomix USA laboratory.

Patient name (Print): ___________________________________________________________________ Date: _________________________

Patient name (Signature): ________________________________________________________________ Date: ________________________

1: If your payment is returned unpaid, you authorize us to debit your account

or process a demand draft for a return check service charge of $50.00.

Igenomix New York Igenomix Los Angeles Igenomix Miami

infousa@igenomix.com 101 Hudson Street Suite 2182 406 Amapola Ave Suite 215 7955 NW 12th Street Suite 415
Jersey City, NJ 07302 Torrance, CA 90501 Miami, FL 33126
www.igenomix.com P +1 (201) 633-6432 P +1 (310) 618 0618 P +1 (305) 501 4948
F +1 (786) 401 7546 F +1 (786) 401 7546 F +1 (786) 401 7546
 Pioneers in Reproductive Medicine and Genetics

FINANCIAL INFORMATION for PGD, PGS, ERA, POC and SAT (Sperm Aneuploidy Testing)

Thank you for choosing Igenomix USA. Igenomix USA is an international team with broad experience in pioneering genetic and molecular diagnosis. Our
goal at Igenomix USA is to provide superior genetic testing services to you to help you along your journey to build a healthy family. We are trusted based
on our expertise and high quality services. You may have already received information and a consent about this testing. If you are interested in more
information, please let us know.
If you would like to proceed with PGS, PGD, ERA, POC or SAT, you must fax, email, or mail these completed documents to Igenomix USA: Payment
Authorization form, HIPAA and Consent Form with signature (if not already forwarded from your clinic).
The services provided by Igenomix USA are billed separately from the rest of your fertility treatments

TESTING WILL NOT BE INITIATED WITHOUT PAYMENT. TO MAKE SURE YOUR WORKUP OR RESULTS ARE NOT DELAYED PLEASE ADHERE TO OUR FINANICAL
POLICY.

Contact Information:
Igenomix USA
7955 NW 12th Street, Suite
415 Miami, FL 33126
P +1(305) 501-4948
F +1(786) 401-7546
Email: infousa@igenomix.com

FINANCIAL POLICY
Below are the details regarding our Financial Policy. You must read, agree, and sign before we can provide services to you.
GENERAL POLICY
 Accurate and current registration information is required.
 Our Company requires advanced payment for our services; payment procedures per test are the following:
o PGS testing for aneuploidy and/or structural chromosome rearrangements (including translocations and inversions) requires payment of
the Preliminary Invoice prior to receiving your samples. The preliminary invoice covers up to a specified number of embryos (see the
preliminary invoice). Any additional embryos received beyond that number will be subject to additional charges. The preliminary invoice
includes one shipping fee. Additional charges apply for additional shipments. Any additional fees will be collected after the report is
released.
o PGD The final prices for PGD for single gene disorders will depend on the mutation(s) being tested for, classified as "common" or "non-common".
A partial payment of $900.00 for “common” cases and $1900 for “non-common” cases is due upon receipt of DNA samples for the PGD workup.
The remaining balance must be paid before the report will be issued.
o ERA and SAT payment form must be received with the sample. This testing will not be initiated until payment is received. To avoid delay in
your testing, be sure all the necessary credit card information is correctly filled out.
o POC payment form must be received with the sample with credit card information except if you have insurance coverage. In these
cases, a copy of the insurance card should be submittedalong with the payment form.
 Full payment includes the cost of the test and any shipping and handling/courier fees. Shipping and handling/courier fees may vary, from $30-
$375.
 We accept personal check, cashier’s check, money order, Visa, MasterCard, American Express and Discover. Personal checks, cashier’s checks,

and money orders should be mailed directly to our laboratory with the accompanying forms. Checks should be payable to Igenomix USA.
 Currently we do not participate directly with insurance companies. Once your service has been paid in full, we can provide you with an itemized
bill which includes the service date, ICD-9 code(s) if provided by your physician, and CPT codes for you to submit directly to your insurance
company as a claim to be reimbursed. This bill typically takes about 2-3 weeks to process once testing is complete. Igenomix USA does not file
claims to insurance companies except for the POC test.

If payment is not received on a timely matter you will be charged additional fees.

By signing the financial consent, you are hereby authorizing future charges on your credit card for additional shipments, additional embryos
beyond the number indicated on the Preliminary Invoice, and subsequent tests.
CANCELLATION FEES
 The cancellation fee policies apply regardless of the reason for cancellation which includes medical and personal reasons.
 For single gene disorders, if you have paid for a pre-cycle workup and the cycle is cancelled, the partial payment fees will not be refunded. If the
workup has been started, but is not completed, this fee is still non-refundable.
 For cancellations of PGS testing, Sperm Aneuploidy, POC, and/ or ERA, you will be refunded the full cost of the test. You will also be
refunded the shipping and handling/courier fee if the courier was cancelled at least one business day in advance.
 To obtain a refund or for questions about the financial policy, contact us directly using our provided contact information. Refunds typically take
2-3 weeks to process.

Igenomix New York Igenomix Los Angeles Igenomix Miami

101 Hudson Street Suite 2182 406 Amapola Ave Suite 215 7955 NW 12th Street Suite 415
infousa@igenomix.com Jersey City, NJ 07302 Torrance, CA 90501 Miami, FL 33126
www.igenomix.com P +1 (201) 633-6432 P +1 (310) 618 0618 P +1 (305) 501 4948
F +1 (786) 401 7546 F +1 (786) 401 7546 F +1 (786) 401 7546