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Maven Network Exception Request Form
Please submit this form to request an exception to utilize a fertility clinic or provider that is out-of-network with Maven. The Maven team will review your request and provide a decision within 3 business days.
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1.
Your Name (first, last)
(Required.)
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2.
Your Date of Birth (MM/DD/YYYY)
(Required.)
3.
Your Partner's Name, if applicable (first, last)
*
4.
Employer sponsoring your fertility benefits
(Required.)
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5.
Your preferred email address
(Required.)
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6.
Zip code where you are located
(Required.)
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7.
Which best describes the stage of your journey?
(Required.)
Considering fertility treatment and looking for a clinic
Recently selected a fertility clinic and have an upcoming first appointment
Recently completed diagnostic testing with a fertility clinic
Currently undergoing an IUI cycle
Recently completed an IUI cycle
Currently undergoing an egg freezing or IVF cycle
Recently completed an egg freezing or IVF cycle and have frozen eggs/sperm/embryos stored at the fertility clinic
Not currently undergoing fertility treatment, but have frozen eggs/sperm/embryos stored at a fertility clinic
Other (please specify)