Mid-Iowa         Please contact your insurance company prior to your appointment to receive 
FERTILITY      information about your benefits for our office. Bring this form along with 
Extraordinary Care…	your patient registration forms to your initial appointment so we can load it into your 
Extraordinary Results     chart. If you do not have any fertility benefit, please indicate that on your form.

Questions for Your Insurance Company

Today’s date: ___/____/____ PATIENT NAME__________________________Date of birth_____________

Insurance Contacted: _______________________________ Contact Name: ________________________

Insurance ID#________________  Group #__________ Single policy or family?____________________

You will want to inform Customer Service that you are calling for FERTILITY BENEFITS

1) Does my plan have fertility benefits? ________________________________________________________
2) Does my plan cover fertility testing? ________________________________________________________ 
3)  What fertility services require a prior approval?_______________________________________________
	If so, what is the phone number my doctor should call for prior approval?________________________
4) Does my policy cover fertility treatment procedures such as insemination (CPT code #58322)?__________
5) Does my policy cover in vitro fertilization (CPT code #58970 & 58974)?_____________________________ 
	If so, what is my dollar maximum for fertility?_________________Is it a number of attempts?_______
7) Do I have benefits for genetic testing on embryos? (Codes #81228) _____________________
8) Do I have coverage for chromosome testing? (this is not testing of embryos) #88230, #88290?__________
	Is prior approval required? If so, what phone number do I call for approval?______________________
9) What specialty pharmacy must I use for self-injectable fertility medications?__________________________
	And what is their phone number?______________________________
What is my copayment?__________What is my deductible for office services?_____________________

What is my co-insurance for office services?________________What is my out of pocket?___________

With this completed form our financial department can assist you with your estimated out of pocket for proposed treatment once we have a quote of benefits from your insurance company. Be sure to save a copy for yourself.

Email or fax this to Monica, our Financial Coordinator at (515) 222-3060 ext. 103 or email her
monica@midiowafertility.com