Infertility Treatment Pre-Authorization Request Form
Patient Information
Full Name
Date of Birth
Member ID
Phone Number
Address
Provider Information
Provider Name
NPI Number
Phone Number
Fax Number
Clinic Address
Requested Treatment
Treatment Type
IVF
IUI
Medications Only
Other
If Other, Please Specify
Requested Start Date
Clinical Information
Diagnosis
Relevant History & Previous Treatments
Current Medications
Supporting Documentation
Documents Attached
Provider Signature
Name
Date