Mark R. Bush, M.D., FACOG, FACS
Michael S. Swanson, M.D., FACOG
Dana R. Ambler, D.O., FACOOG
Ryan M. Riggs, M.D., FACOG
Patient: _________________________ DOB: __________ Partner: _______________________ DOB: __________
Karyotype (Chromosome Testing) Financial Consent Form
What is a karyotype and how can it help me achieve a healthy pregnancy?
“A karyotype, usually obtained from a blood specimen, describes the number and appearance of your chromosomes.
Couples who may benefit from this test are those with infertility, poor egg health (diminished ovarian reserve),
abnormal semen analysis and recurrent pregnancy loss. Some studies estimate the rate of a karyotype abnormality to
be approximately 4 – 11 times greater than the rate in the general population in patients with recurrent pregnancy loss
(0.72% vs. 3 – 8%) and approximately 2 times greater than the rate in the general population in patients with infertility
(0.72% vs. 1.3 – 1.5%). Equally important, if an abnormality is detected, genetic testing of your embryo(s) will allow us to
identify and select unaffected (normal) embryo(s) for pregnancy.”
How much does a karyotype cost and who pays for it?
Insurance coverage for chromosome testing depends largely on your clinical medical situation and your insurance plan.
Please note that a karyotype is NOT part of any Conceptions treatment package and is completed by an independent
laboratory. The insurance billed rate for this test ranges from $750 - $1,115 and is processed according to individual
health plan coverage. **Non-Insured patient’s may utilize CLS for a private pay rate of $250**
Because we are unable to guarantee insurance coverage we strongly recommend you independently verify coverage for
your individual plan directly with your insurer. Please be aware denied insurance claims will be billed to you directly at
the standard rate. To assist with verification of chromosome analysis testing coverage when contacting your insurance
you will need PROCEDURE CODES 88230 and 88261 along with one of the following diagnosis codes that pertain to you:
Female Diagnosis: V26.32 (other genetic disease carrier status) or 629.81 (history of recurrent pregnancy loss)
Male Diagnosis: V26.34 (other genetic disease carrier status) or V26.35 (history of current partner with recurrent pregnancy loss)
I ELECT to have Chromosome Analysis testing and understand I am responsible for all outside lab fees associated
with the Chromosome Analysis testing.
I DECLINE to have Chromosome Analysis testing and understand and accept the consequences of this decision.
My Partner ELECTS to have Chromosome Analysis testing and understands he/she is responsible for all outside lab
fees associated with the Chromosome Analysis testing.
My Partner DECLINES to have Chromosome Analysis testing and understands and accepts the consequences of this
decision.
______________________________________________________
Patient Signature
________________________
Date
______________________________________________________
Partner Signature
________________________
Date
______________________________________________________
CRA Witness
________________________
Date
CONCEPTIONS REPRODUCTIVE ASSOCIATES OF COLORADO
CONCEPTIONS REPRODUCTIVE
ASSOCIATES OF COLORADO
www.conceptionsrepro.com
____________________________________________________________________________________________________________________________________
www.conceptionsrepro.com
271 W County Line Rd
Littleton. CO 80129
T: 303.794.0045
F: 303.794.2054
4500 E. 9th Avenue, Suite 630
Denver, CO 80220
T: 303.720.7887
F: 720.763.9140
300 Exempla Cir., Suite 370
Lafayette, CO 80026
T: 303.449.1084
F: 303.449.1039
10099 RidgeGate Pkwy, Suite 260
Lone Tree, CO 80124
T: 303.586.6598
F: 720.459.5112
Updated
Updated
02-06-14 MRM