RMA IVF Grant Application | Michigan
Questions
Personal Information
Name
*
First Name
Last Name
DOB
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Employer Name
Position
Annual Salary
Partner Information
Name
*
First Name
Last Name
DOB
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employer Name
Position
Annual Salary
Fertility Information
How long have you been trying to conceive?
*
Are you using a surrogate to carry?
*
Please Select
Yes
No
Have you ever been pregnant?
*
Please Select
Yes
No
Are you using an egg donor?
*
Please Select
Yes
No
Have you had or started infertility treatment?
*
Please Select
Yes
No
Have you been diagnosed by a physician with infertility such as low egg reserve, low sperm count, or unexplained?
*
Please Select
Yes
No
Please Explain...
*
Please Explain Diagnosis...
*
Background Information
Have YOU ever been convicted of a felony or misdemeanor?
*
Please Select
Yes
No
Has YOUR PARTNER ever been convicted of a felony or misdemeanor?
*
Please Select
Yes
No
Please Explain...
*
Please Explain...
*
Annual HOUSEHOLD Income
*
Income Sources
*
Work
Alimony
Child Support
Disability
Other
Do you or your partner have health insurance?
*
Please Select
Yes - just me
Yes - just them
Yes - both
No
Do you or your partner have IVF coverage with your health insurance?
*
Please Select
Yes - just me
Yes - just them
Yes - both
No
Referral Information
Personal Referral Name 1
*
First Name
Last Name
Phone Number 1
*
Please enter a valid phone number.
Format: (000) 000-0000.
Personal Referral Name 2
*
First Name
Last Name
Phone Number 2
*
Please enter a valid phone number.
Format: (000) 000-0000.
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IVF Application
File Uploads
Signed Brilora Grant Overview Form
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Copy of Your and Your Partner's Insurance Cards
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Signed Permission to Release Information Form
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Driver's License Copy
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Copy of YOUR Latest Paystub
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Copy of YOUR PARTNER'S Latest Paystub
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Signed HIPAA Authorization Form
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I attest that all of the information provided is true and accurate to the best of my knowledge.
*
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