Get Infertility-services-precertification-request-form. Accessible

Filling out the infertility-services-precertification-request-form is an important step in obtaining medical services for infertility treatments. This guide will help you navigate through the form with clarity and confidence, ensuring all necessary information is provided accurately.

Follow the steps to complete the form with ease.

1. Click the ‘Get Form’ button to access the form and open it in your document editor.
2. Section 1 must be completed by the Provider or their office staff. Provide the member’s name, ID, date of birth, and the requesting provider’s information including name, TIN or NPI, fax number, and a contact person’s details.
3. In Section 2, select the requested service and provide details of the treatment plan. Specify if donor sperm or eggs are used and enter the start date of the cycle.
4. Section 3 requires the member's clinical history. Enter details such as the date of the last menstrual period, FSH level, E2 level, AMH level, and any medications the member was on at the time of blood work.
5. Continue with Sections 4 to 6, which cover specific infertility histories and treatment records. Answer yes or no to each question, providing necessary documentation and details.
6. Section 7 reiterates the importance of accuracy while filing the request. Make sure you understand the implications of providing false information.
7. Finally, sign and date the form in Section 8. Once completed, take the time to review the form for any errors.

Start completing your infertility-services-precertification-request-form online today to ensure timely assistance with your healthcare needs.