Imagine Fertility Package

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Certification of Insurance benefits Exhaustion/Exclusion
Enrollee's health care does not cover drugs for Infertility.
Enrollee has exhausted her/his health care insurance for Infertility drugs.

Authorization for Disclosure of Protected Health Information

I authorize Imagine Fertility to disclose my Protected Health Information to the Fertility Center indicated on this form and their contracted pharmacy business asscoiates.

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Description of Information to be Released
Medical Prescription

Person Authorized to Receive Information
I have read and understand the above information. My submission of this form authorizes disclosures of Protected Health Information to Imagine Fertility.