Sample Insurance Letter Dear Patients, This is a sample form letter you can use to request information regarding your fertility coverage from your insurance company. The information (in parentheses) should be completed by filling in the boxes with information specific to your case. We have listed the relevant questions you need to ask to confirm all aspects of your fertility coverage. If this request is sent as a letter via certified mail, the receipt will confirm your insurance company received your request. You may elect to call your insurance company. It is a good idea to get the name of the person with whom you are speaking and jot down the date and time of your conversation.

Insurance Company XYZ 123 Main Street Anytown, CA 55555 Today's Date Re: Predetermination of benefits for (patient's name) ID number: (patient's insurance identification number) Group or Group number: (group name or number) (Find your group and/or ID number and mailing address on your insurance card. This information allows the insurance carrier to locate your group or individual policy and determine benefits). Dear Insurance Company XYZ, I am considering infertility services with Select a Doctor Select a Doctor Dr. Carolyn Givens Dr. Isabelle Ryan Dr. Eldon Schriock Dr. Philip Chenette Dr. Carl Herbert . My partner and I are seeking infertility services due to (explain your situation, e.g., blocked fallopian tubes, male factor, previous sterilization, unexplained infertility, etc). Please provide me with a written response to each question below. Do I have infertility benefits under my current insurance coverage? Do these infertility benefits allow me to see an “out-of-network” physician? What percent of the cost would I be expected to pay for infertility treatment with an “out of network” fertility physician? Do I have diagnostic infertility coverage allowing the physician to find the cause of my infertility problem? Do I have infertility treatment coverage allowing the physician to perform intrauterine insemination? Do I have infertility treatment coverage for in vitro fertilization? Does this coverage include cryopreservation, intracytoplasmic sperm injection and/or frozen embryo transfer? If yes, does my policy require prior authorization for these procedures? If I have fertility coverage for these procedures, what is my maximum infertility benefit? Does my policy cover injectable medications? If yes, does my policy require prior authorization for injectable medications? Do I need to use a specific laboratory? Do I need a referral to visit Select a Doctor Select a Doctor Dr. Carolyn Givens Dr. Isabelle Ryan Dr. Eldon Schriock Dr. Philip Chenette Dr. Carl Herbert for an initial consultation? I would appreciate a response as soon as possible as I will be seeing my physician in the near future. Thank you. Sincerely, (patient's name)