Infertility Services Precertification Form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section 1 by entering the member's general information, including their name, reference number, and contact details. Ensure all fields are completed accurately.
3. Move to Section 2 to outline the treatment plan. Select the requested service and provide any necessary medication details. Be sure to include the planned start date for treatment.
4. In Section 3, document the member’s clinical history. Fill in details regarding previous pregnancies, partner information, and any relevant medical history.
5. Proceed to Section 4 where you will need to attach specific documentation related to the request. Follow the guidelines provided for each type of treatment.
6. Complete Section 5 by detailing any advanced reproductive technology requests and previous ART cycles if applicable.
7. Finally, review all sections for accuracy before signing in Section 7. Remember that this form cannot initiate a precertification request; submit it electronically or call the Precertification Department.

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