Emergency Contact Information - If we urgently need to speak with you about an order and cannot reach you, we may contact this individual.
Based on your answers above, we need to make a further determination as to whether your donor'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.
Major Medical Insurance Information

If your insurance is covering all or some of the donor'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

Intended parents paying out of pocket for Donor Cycle:
If you do not have coverage for your donor's medication order, we have discount programs to ensure competitive pricing for the medications ordered for your donor.
For Intended Parents that have coverage for their Donor Cycle with Medical or Pharmacy Benefits: If you have coverage through your insurance policy, please note that since the donor 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 donor, it is your insurance company's responsibility to ensure that your claims are processed and you receive reimbursement accordingly.

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