Patient Centered - Quality Assured - Physician Recommended
888-580-TRAK(8725)
 
  REGISTRATION
 
To understand Why Your OB Recommends CordTrack and for Pricing Information, please complete the simple registration form below.

CordTrack protects your privacy.  No information will be disclosed for any reason to any other entity outside of CordTrack.

ACCOUNT INFORMATION
 
*First Name:
*Last Name:
*Email:
*Password:
*Confirm Password:
Phone:
 
OB & Hospital Information
 
*Expected Due Date:  (mm/dd/yyyy)      
 
Your OB
*First Name:
*Last Name:
 
Your OB's Practice
*City:
*State:    
*Expected Delivery Hospital:    
 
I hereby give my consent for my OB’s medical practice (the "Medical Practice") to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations in connection with the storage of umbilical cord blood following the deliver of my baby (“TPO” total patient operations). (The Notice of Privacy Practices provided by the Medical Practice describes such uses and disclosures more completely.)

I have the right to review the Notice of Privacy Practices prior to signing this consent. The Medical Practice reserves the right to revise its Notice of Privacy Practices at any time.

With this consent, the Medical Practice or CordTrack on behalf of the Medical Practice may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.

With this consent, the Medical Practice or CordTrack on behalf of the Medical Practice may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”

With this consent, the Medical Practice or CordTrack on behalf of the Medical Practice may e-mail to my home or other alternative location any items that assist the Medical Practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that the Medical Practice or CordTrack on behalf of the Medical Practice restrict how it uses or discloses my PHI to carry out TPO. The Medical Practice is not required to agree to my requested restrictions, but if it does, it will be bound by such agreement.

By checking "yes" below, I am consenting to allow the Medical Practice or CordTrack on behalf of the Medical Practice, as appropriate, to use and disclose my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the Medical Practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, the Medical Practice may decline to provide professional services in connection with the storage of umbilical cord blood following the deliver of my baby.
 
 
Associate a Doctor
The information you entered about your OB matches other doctors who are already enrolled with CordTrack.

Below are doctors who match your entry. If your doctor is listed please click on that doctor and select your hospital from the drop down list. If you do not see your doctor listed please click the CANCEL button to save the doctor information you already entered on the previous form.

Hospital:

CordTrack Partners, LLC
Corporate Office: 6518 Highcroft Lane, Naples, FL 34119 • 1-888-580-TRAK (8725)