Device Consent

Doctor approval and the corresponding signed patient consent form must be received before the ordering process can begin.

Our office will verify your insurance coverage for the procedure. If your insurance plan has 100% contraceptive coverage, your order will process through the specialty pharmacy or our office. If you have a financial responsibility that exceeds your copay, you will be notified to see if you wish to proceed.

The prescription is then faxed to the specialty pharmacy that is contracted with your insurance. They will verify your benefit information for the device only. Please allow 2-6 weeks.

The specialty pharmacy may need to contact you regarding your financial responsibility and/or to get final approval to ship. This phone call may be required to finalize the order.

Our office will notify you when your device arrives. All placements must occur within the first 5 days of your period unless you are breastfeeding, 6 weeks postpartum, or currently have a device in place.

A Mirena IUD prevents pregnancy for up to 7 years, and also helps with heavy periods for up to 5 years in women who choose an IUD for birth control.
Mirena IUD (J7298)

Consent Form
Kyleena Is the Smallest, Lowest Dose 6-Year IUD
Kyleena (J7296)

Consent Form
Paragard is a small, 100% hormone-free IUD (intrauterine device)—also known as an IUS (intrauterine system)—that’s over 99% effective at preventing pregnancy.
Paragard IUD (J7300)

Consent Form
Liletta® (levonorgestrel-releasing intrauterine system) 52 mg is a hormone-releasing system placed in your uterus to prevent pregnancy for as long as you want for up to 5 years.
Liletta Code (J7297)
What is Skyla? Discover an IUD (intrauterine device) that is over 99% effective for up to 3 years.
Skyla (J7301)

Consent Form
Nexplanon is a low-maintenance birth control that’s non-daily, over 99% effective, and lasts for 3 years, unless you want it taken out sooner.
Nexplanon (J7307)

Consent Form