Fertility Lifelines Form PDF Details

Embarking on the path to parenthood can be a journey filled with hope, struggles, and at times, the need for medical assistance. To support those facing fertility challenges, the Fertility Lifelines form serves as the gateway to the Compassionate Care Program, offering crucial assistance to individuals and couples during their fertility treatments. Tailored to gather patient information in a structured way, this form asks for basic personal details, treatment history, and requires applicants to disclose insurance coverage status to ensure eligibility criteria are met. It emphasizes the importance of transparency about any changes in insurance status, ensuring those enrolled remain eligible for the program's benefits. Additionally, it highlights a unique consideration for military personnel, acknowledging their service by requesting specific information regarding active or retired status. The form also delves into the specifics of the fertility treatments being pursued, asking about diagnoses and past participation in the program. Furthermore, it outlines the documentation needed for income verification, a crucial step in assessing the financial eligibility of applicants. The process is rounded off with an authorization segment, where applicants consent to the sharing of their personal and health information, aiming to streamline their participation in the Compassionate Care Program. This form not only represents a beacon of hope for many but also a testament to the compassionate support systems in place to aid individuals navigating the complexities of fertility treatments.

QuestionAnswer
Form NameFertility Lifelines Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namescompassionate care enrollment form, compassionate care patient enrollment form, fertility lifelines form, compassionate care form get

Form Preview Example

Compassionate Care Program

PATIENT ENROLLMENT FORM

 

Phone: (855) 541-5926 Fax: (919) 415-2870

`

PATIENT INFORMATION Please remember that your program eligibility requires that you promptly notify the Compassionate Care Program by calling (855) 541-5926 if you become insured by any private or government insurance plan

FIRST

 

 

 

 

 

LAST

 

MI

NAME

 

 

 

 

 

NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF

 

□ Male

□ Female

By providing your e-mail address, you consent to receive additional mailings from the Compassionate Care Program.

GENDER

E-MAIL

 

 

BIRTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOME

 

 

 

 

 

 

MOBILE

 

 

PHONE

 

 

 

 

 

 

PHONE

 

 

 

 

 

 

 

 

 

 

 

 

MAILING

 

 

 

 

CITY

STATE

ZIP

ADDRESS

 

 

 

 

CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PREFERRED METHOD OF CONTACT

 

 

 

 

 

 

 

 

□ Home phone □ Mobile phone □ Mail □ E-mail

 

 

 

COUNTRY

 

 

 

 

 

 

 

 

 

 

 

Please indicate if you or your partner are active duty US Military: □ Yes (Indicate branch):____________________ □ No

 

Please indicate if you or your partner are a retired member of the US Military: □ Yes (Indicate branch):____________________ □ No

If you are a retired member of the US Military, please attach a copy of your DD-214

 

 

If you’re unavailable when we call, is it OK for us to leave a message, including the Compassionate Care Program name? □ Yes □ No

TREATMENT

Are you currently undergoing fertility treatment with a fertility specialist? □ Yes □ No

Has your physician diagnosed you as requiring assisted reproductive technologies (such as IVF)? □ Yes □ No

Have you ever received products through the Compassionate Care Program in the past? □ Yes □ No

I have been prescribed the following: □ Any Gonal-f® (follitropin alfa for injection) product □ Cetrotide® (cetrorelix acetate for injection)

□Ovidrel® PreFilled Syringe (choriogonadotropin alfa injection)

FAX, MAIL, OR E-MAIL YOUR INCOME VERIFICATION FORM TO:

Fax: (919) 415-2870 Mail: The Compassionate Care Program • 6501 Weston Parkway, Suite 370 • Cary, NC 27513

E-mail: enrollments@emdcompassionatecare.com

We will need to know the annual adjusted income for the entire household. The following are acceptable income documents that we can use to validate your income:

□ 1040 Form

□

□ 1040A Form

□

□ 1040EZ Form

□

1040 Form Married Filing Separately (MFS) (Need a form from both filers) 1040A Form (MFS)

W2/1099R Form

□

□

□

1099 Form

Pension Notification Letter

Social Security Award Letter

How many people live in your household?

PATIENT SIGNATURE AND AUTHORIZATION:

Fax: (919) 415-2870 Mail: Compassionate Care Program • 6501 Weston Parkway, Suite 370 • Cary, NC 27513

My signature below certifies that I have completed all of the above sections completely, accurately, and to the best of my knowledge and that I have read, understand, and agree to the terms of this enrollment form and the attached Authorization to Use and Disclose Health and Other Personal Information form. I commit to making the Compassionate Care Program aware, if at any time, I gain insurance coverage for infertility treatment. No units of product received under this program will be submitted for Medicare, Medicaid, TRICARE, the Department of Veterans Affairs, the Department of Defense, or any public or private third-party reimbursement, or returned for credit.

Please remember that your program eligibility requires that you promptly notify the Compassionate Care Program by calling (855) 541-5926 if you become insured by any private or government insurance plan.

PATIENT SIGNATURE

PATIENT NAME

DATE

 

ART CENTER CONTACT OR SITE NAME:

 

If applicable, please provide an e-mail address for the person who manages the Compassionate Care Program at your ART Center.

 

 

 

 

 

ART

 

CONTACT

 

CENTER

 

E-MAIL

 

 

 

 

 

 

For assistance or additional information, call (855) 541-5926 Monday to Friday, 8:00 AM to 8:00 PM EST

 

 

 

 

 

US-NON-0514-0035

 

WEBSITE ENROLLMENT FORM

AUTHORIZATION TO USE AND DISCLOSE HEALTH AND OTHER PERSONAL INFORMATION

Patient’s Name

 

 

 

 

 

_

Address

 

 

 

 

 

 

__

Home Phone

 

 

DOB

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I authorize my physician and his/her staff to disclose my health and other personal information, including, but not limited to, the information on this form, to EMD Serono, Inc. and its agents and representatives including any company that helps administer EMD Serono’s Compassionate Care Program (collectively “EMD Serono”) so that EMD Serono may use and further disclose my information to healthcare providers, pharmacies, insurance companies, prescription drug plans and other third-party payers (collectively, “Third Parties”) in order to:

(1)contact me by mail, e-mail, and/or telephone to enroll me in, and administer EMD Serono’s Compassionate Care Program;

(2)provide me with materials relating to EMD Serono’s Compassionate Care Program;

(3)verify the accuracy of the information I provide and in my application for EMD Serono’s Compassionate Care Program;

(4)conduct surveys to measure my satisfaction with EMD Serono’s Compassionate Care Program.

I further authorize the Third Parties to disclose health and other personal information about me in their possession to EMD Serono in order to assist EMD Serono in accomplishing the purposes described above.

I understand that once my information is disclosed pursuant to this authorization, there is no guarantee that it will not be disclosed to another third party. However, I understand that EMD Serono will not release my information to any party, except as provided in this authorization or as permitted by applicable law, without first obtaining my (or my authorized representative’s) separate written consent.

US-NON-0514-0035

PATIENT MUST SIGN THE BACK OF THIS FORM THEN SEND OR FAX BOTH PAGES

WEBSITE ENROLLMENT FORM

I understand that I may refuse to sign this authorization and such refusal will not affect my ability to receive EMD Serono Products, but it will limit my ability to participate in EMD Serono’s Compassionate Care Program.

I understand that this authorization will remain in effect for ten years from the date of my signature, unless I revoke it earlier by contacting EMD Serono or its representatives in writing by mail or fax at 6501 Weston Parkway, Suite 370, Cary, NC 27513, fax (919) 415-2870. If I revoke this authorization, EMD Serono will stop using and disclosing my information as soon as possible, but the revocation will not affect prior use or disclosure of my information in reliance on this authorization.

I understand that the services provided by EMD Serono that are described in this authorization can be changed at any time, without prior notification.

I also understand that I have the right to receive a copy of this authorization.

Patient name (please print):

Signature of patient (or personal representative):

 

Date:

 

/

/

 

 

 

 

 

 

 

 

 

 

Authority/relationship of personal representative (if applicable):

 

 

 

 

 

 

 

Signature of patient (or personal representative):

 

Date:

 

/

/

 

 

 

 

 

 

 

 

 

Authority/relationship of personal representative (if applicable):

 

 

 

 

 

 

 

US-NON-0514-0035

PATIENT MUST SIGN THE BACK OF THIS FORM THEN SEND OR FAX BOTH PAGES

WEBSITE ENROLLMENT FORM

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2. Just after the previous section is done, go to enter the relevant details in all these - Are you currently undergoing, Fax Mail The Compassionate Care, FAX MAIL OR EMAIL YOUR INCOME, Email, We will need to know the annual, How many people live in your, Fax Mail Compassionate Care, PATIENT SIGNATURE AND AUTHORIZATION, My signature below certifies that, PATIENT NAME, and DATE.

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