processing...

Imagine Fertility Package
Enrollment

Your Demographics

Preferred Method of Communication

Please choose your Fertility Center

Please choose your Doctor
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.

Accept Decline

Description of Information to be Released
Medical Prescription
Other

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.
Confirm