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Insurance Benefits Verification Form

This form enables EMD Serono Fertility Lifelines to investigate your insurance coverage for fertility treatment. Please note: All sections with asterisks are required. If you have any questions, please feel free to contact us toll-free at 1-866-LETS-TRY (1-866-538-7879), or download the form now and fax it to 1-866-538-7879.

Section 1: Patient Information