TUBAL REVERSAL FORMS
FORMS TO COMPLETE FOR TUBAL LIGATION REVERSAL
#1 Sending Us Tubal Ligation Records
Use our upload portal to securely send us your medical records.
If you would like to send us your tubal ligation records for a free review then we strongly recommend you use our HIPAA compliant medical records portal.
A Personal Choice Medical Records Upload Portal
By using our medical records portal you can safely and securely send us your medical records for review.
#2 Medical Records Release Form
Use this form if you are asking the Medical Records Department, hospital, or doctor’s office to send your records to you or A Personal Choice.
Complete our Medical Records Release Form using the link below.
Print the records release, fill in the required information, and fax or mail the release to the Medical Records Department of the hospital where you had your tubal ligation surgery.
Our Medical Records Release Form requests the staff of the hospital or doctor’s office fax or mail your records directly to A Personal Choice along with your signed Medical Records Release. If they do not also send us your signed form with your records, we will not have the necessary information to contact you after we review your records.
We recommend you have the doctor’s office send the records directly to you first. You will know when you get the records. You will have a copy and you can then send them directly to our office for review.
***You are required to send the Medical Release form to your doctor. Our office does not request your records. By sending them this form, you are requesting they provide a copy of your records either to you or to our office.***
Many patients have issues when they ask the doctor or hospital to send records. Occasionally our office will receive the records but will not have your contact information. Sometimes the records are never sent and we will never know that you requested records. and the reality is you never know when (or if) they ever send the records as requested.
We recommend you have records sent directly to you. This is important because you will know when the records are sent and you can make a copy for yourself.
If you would like your medical records sent directly to you then remove or cross out our mailing address and insert your mailing address into the Medical Records Request that you print out. Once you get your records then you will know when you have them. We recommend you make a copy and then fax or email your records to us for review.
We strongly recommend you use our HIPAA compliant Medical Records Upload portal using the link in Form #1 above.
#3 Medical Records Cover Sheet (also called Fax Cover Sheet)
Use this form if you have your medical records and would like to fax or scan and email your records directly to us.
If you already have a copy of your tubal ligation records, please complete our Medical Records Cover Sheet, print it out, and fax or email your records to us directly.
The Medical Records Cover Sheet contains all of your important health and contact information. Without the completed Medical Records Cover Sheet we will not have the necessary information to determine if you are a candidate for surgery. We will not be able to contact you after your records have been reviewed.
- You can fax your medical records along with the completed Medical Records Cover Sheet to: (919) 883-4036.
- You can email your records along with the completed Medical Records Cover Sheet to: ContactUs@tubal-reversal.net
You are welcome to fax or email your records but we recommend you use our HIPAA complaint Medical Record Upload Portal for greater security and privacy using the link in Form #1 above.
#4 Reversal Prepayment Account (RPA) Contribution Form
Use this form if you would like to make a deposit (not the very first deposit) to your Tubal Reversal Prepayment Account. You would have to print this form out and mail it in with your RPA contribution.
Reversal Account Pre-Payment Contribution Form
Please be aware when you open your RPA you will need to sign an RPA contract and make your first deposit using the contract sent to you when you first opened your RPA.
This RPA Pre-payment form is for contributions made to your account after the account has been opened.
#5 Request to close Reversal Prepayment Account Form (RPA)
Use this form if you would like to close your RPA account.
#6 FMLA/Work Release/ Return To Work
Use this form to send us FMLA or return to work forms.
If you are having reversal surgery at our office and you need us to complete documentation allowing you to take time off for reversal surgery, return to work with or without restrictions, or any other documentation required to support your surgery at our office then you will need to complete the FMLA/Work Release/Return to Work form.
FMLA/Work Release/ Return To Work
A $35 fee is required to have our staff complete and return this form.
#7 Release of A Personal Choice Medical Records
We provide all of our patients with a physical copy and a PDF emailed copy of their tubal reversal operative note and a letter of recommendations to their local doctor. If you need these records a second time you will have to submit a Release of A Personal Choice Medical Records using the link below.
Release of A Personal Choice Medical Records
A $35 fee is required to provide you with your records a second time.
#8 Pregnancy Report Form
We want to be informed as soon as you become pregnant after your tubal reversal. You can use the Pregnancy Report Form, or call or email us when you have a positive pregnancy test. An essential part of our long term care is follow-up with you and your local doctor during your pregnancy.
We like to know about all our patients pregnancies… so stay in touch with us!
#9 Birth Report Form
We are eager to hear when your baby is born.
Please complete a Birth Report Form when you have a baby. Once we get your Birth Report, we will mail you a baby t-shirt!
Your comments are extremely important and provide both hope and inspiration for other couples. With your permission, we will add a page for your baby in the Testimonials section of our website.
Preparing For Tubal Reversal
After you have scheduled a date for your tubal reversal, please print out a copy of the Tubal Reversal Surgery Checklist to ensure your successful preparation for your reversal.
