Infertility-services-precertification-request-form Accessible PDF 2025

1. Click ‘Get Form’ to open the infertility-services-precertification-request-form in our editor.
2. Begin with Section 1, providing general information such as the member's name, ID, and date of birth. Ensure all fields are filled accurately to avoid delays.
3. Move to Section 2, where you will outline the treatment plan. Specify the requested services and medications. Be sure to include the start date of the cycle.
4. In Section 3, have a clinician complete the member’s clinical history, including FSH and E2 levels along with their collection dates.
5. Section 4 requires specific documentation based on the type of request. Follow the guidelines carefully to ensure all necessary records are included.
6. Complete Section 5 for Advanced Reproductive Technology requests by detailing previous cycles and any relevant medical history.
7. Finally, review Section 6 for important information regarding fraudulent claims before signing in Section 7. Remember that this form cannot initiate a precertification request directly.

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