Now Offering Affordable Self-Pay Options!

myiud.info@gmailcom

IUD Order Form

HomeIUD Order Form

All Major Commercial and Medicaid Plans Accepted
*some 3rd party HMOs excluded

*UHC insurance is temporarily not accepted.

IUD REQUEST FORM

Please Complete All Sections

"*" indicates required fields

Phone

This field is for validation purposes and should be left unchanged.

Practice State*

State

Health Plan Accepted by State*

Alabama

Health Plan Accepted by State*

Arizona

Health Plan Accepted by State*

Florida

Health Plan Accepted by State*

Georgia

Health Plan Accepted by State*

Illinois

Health Plan Accepted by State*

Kentucky

Health Plan Accepted by State*

Louisiana

Health Plan Accepted by State*

Michigan

Health Plan Accepted by State*

Mississippi

Health Plan Accepted by State*

Nevada

Health Plan Accepted by State*

New York

Health Plan Accepted by State*

North Carolina

Health Plan Accepted by State*

Ohio

Health Plan Accepted by State*

South Carolina

Health Plan Accepted by State*

Tennessee

Health Plan Accepted by State*

Texas

Health Plan Accepted by State*

Wisconsin

Practice Name*

Provider Name*

Email*

Patient Name*

Patient DOB*

Patient Phone*

Patient Street Address*

Patient Street*

Patient City*

Patient State*

Patient ZIP*

This field is hidden when viewing the form

Insurance Name

Insurance ID#

Type of IUD*

Scheduled Date of Insertion

Patient HIPAA Authorization and Consent Form

Please have your Patient Review our Privacy Policy and sign the HIPAA Authorization and Consent Form to complete the IUD Order Process

[sp_easyaccordion id="7522"]

Patient Name*

Date*

Patient Signature*

Practice Representative*

CAPTCHA

*MyIUDSupply will contact the patient for order confirmation

IMPORTANT: Prescriber gives MyIUDSupply.com express permission to use his/her NPI number included herein for the purpose of identifying the referring prescriber to the authorized pharmacy benefits manager and/or payer. MyIUDSupply.com accepts no liability regarding any decisions concerning claims, coverage or payment, which are made in the sole discretion of the health plan administrators and insurers. MyIUDSupply.com makes no assurance that any prescribed drug will be covered or reimbursed at any specific level under any patient’s insurance plan, or that any specific pharmacy will provide the prescribed drug.

Please check your email for your order confirmation