3RD PARTY FORM - INTENDED PARENT - GESTATIONAL CARRIER CYCLE.

First Name *

Last Name *

Date Of Birth *

Street Address *

Address Line 2

City *

State *

Country *

Zip Code *

Phone Number *

This phone number is: *

Email Address *

Emergency Contact Information - If we urgently need to speak with you about an order and cannot reach you, we may contact this individual.

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone Number *

Emergency Contact Email Address *

May we disclose information about your treatment and/or order to your Emergency Contact? *

Please confirm the name of your Gestational Carrier. *

Do you know when your gestational carrier needs their medication by? *

When does your Gestational Carrier begin her medications? *

In general, do you have fertility benefits for yourself through your insurance plan? *

Does your fertility benefit extend to third party procedures such as donor egg and/or gestational carrier procedures? *

If your major medical plan offers coverage for your gestational carrier's procedures, do you intend to use this coverage or will you pay separately from your major medical plan? *

Based on your answers above, we need to make a further determination as to whether your gestational carrier's procedures will be covered under your major medical insurance benefits. Please provide your medical insurance information below so that we can investigate. We ask that you also provide your prescription insurance information so we can investigate further if we discover third party coverage under your major medical.

INSURANCE INFORMATION

Major Medical Insurance Information

How do you want to provide your major medical insurance information? *

Medical Insurance Card - FRONT *

Medical Insurance Card - BACK *

Name of Major Medical Insurance

Member Services Phone Number for Insurance

Medical ID #

Name of Insured's Employer *

If your insurance is covering all or some of the carrier's procedures, we will need to investigate if the coverages extends to the medications. In this case, we will need the following information in order to investigate your coverage:

Prescription Insurance Information

How do you want to enter your prescription insurance information? *

Rx Insurance Card - FRONT *

Rx Insurance Card - BACK *

Prescription Insurance Company Name *

RXBIN *

ID *

RXGRP *

PCN (or processor control number) *

Primary plan member name (if not you)

Intended parents paying out of pocket for Carrier:

If you do not have coverage for your carrier's order, we have discount programs to ensure competitive pricing for the medications ordered for your Gestational Carrier.

For Intended Parents that have coverage for the Gestational Carrier with Medical or Pharmacy Benefits: If you have coverage through your insurance policy, please note that since the carrier is not an actual member on your plan, it is likely that you will have to pay for the medications at the insurance company's rates, and then submit a paper claim for reimbursement. We will provide you with a claim form as well as the receipts required to facilitate your claim. Reimbursement cannot be guaranteed by Mandell's. Although the investigation may show that you have coverage for the carrier, it is your insurance company's responsibility to ensure that your claims are processed and you receive reimbursement accordingly.

Will your doctor’s office be submitting a medication order for your portion of the cycle medications to Mandell’s? *

Allergies - Food, medications, latex or ANY other potential allergies. If none, please type "none". *

Medical Conditions - If none, please type "none". *

List any medications or vitamins you are taking, whether prescribed or over the counter. If none, please type "none". *

When do you need to begin your medications *

Would you like Mandell's to investigate your prescription benefits for your own medications? *

How do you want to provide your prescription insurance information? *

Rx Card - FRONT *

Rx Card - BACK *

Prescription Insurance Name *

RXBIN *

ID# *

RXGRP(if present) *

RXPCN *

Primary plan member name (if not you) *

Once you complete this form in it's entirety, please verify the accuracy of the information and then click "Submit"