Infertility Authorization Form: Insemination Cycles (AI or IUI ... 2026

1. Click ‘Get Form’ to open the Infertility Authorization Form in the editor.
2. Begin by entering the Member's information, including Name, DOB, Age, and ID#. Ensure accuracy as this data is crucial for processing.
3. Fill in Partner's details similarly. This section requires their Name, DOB, Age, and ID#.
4. Provide Prescribing Provider information including Name, ID#, Phone #, and Fax #. Don’t forget to sign and date the request.
5. Detail the Member’s Diagnosis by selecting from options like Tubal/Endo or Male Factor. Include any additional notes if necessary.
6. Indicate the length of time trying to conceive and provide relevant Pregnancy Dates/Pregnancy Outcomes.
7. Complete sections on requested services and CPT/HCPCS codes as applicable. Attach any required supporting documentation for a smooth review process.

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