Insurance Prescription Plan Coverage Form
Fax to 619-445-1995

FertilityMeds excepts most insurance prescription plans. We will be happy to contact your insurance company to verify coverage and advise you accordingly. Please provide the information below and return it to us via fax (619-445-1995) or click here to go to our online submission form.

Insurance Company	__________________________	Policy Number	__________________
Group Number	__________________________	Insurance Co. Phone Number	__________________
Primary Insured's Name:	__________________________	Primary Insured's ss #	__________________
Patient Name: _______________________   Home Phone: _______________________   Work Phone: _______________________     Home Address: ______________________________________________________________ City, State, Zip: ______________________________________________________________ Note: In order to check your insurance coverage, FertilityMeds must have a copy of your prescription. If you need help getting your prescription to us, click here or contact us Toll Free (800-364-9660)