Compassionate Care Application
All fields require an answer, unless otherwise noted
Requires dates of service*
*for/of military personnel
Requires PDF upload*
*1st page of Form 1040 or 1099, proof of spouse's income (if you file separately), &/or proof of unemployment (if unemployed).
Submission may take a few minutes, please be patient.
Please be prepared to upload a copy of a filed tax return (Max. file size 20MB. PDF files only)
Forms Accepted as Proof of Income:
IMPORTANT: Please read the following to the end. You must acknowledge and accept the terms prior to proceeding.
I authorize my physician and his/her staff to disclose my health and other personal information, including, but not limited to, the information on this form, to EMD Serono, Inc. and its agents and representatives including any company that helps administer EMD Serono’s Compassionate Care Program (collectively “EMD Serono”) so that EMD Serono may use and further disclose my information to healthcare providers, pharmacies, insurance companies, prescription drug plans and other third-party payers (collectively, “Third Parties”) in order to:
I further authorize the Third Parties to disclose health and other personal information about me in their possession to EMD Serono in order to assist EMD Serono in accomplishing the purposes described above.
I understand that once my information is disclosed pursuant to this authorization, there is no guarantee that it will not be disclosed to another third party. However, I understand that EMD Serono will not release my information to any party, except as provided in this authorization or as permitted by applicable law, without first obtaining my (or my authorized representative’s) separate written consent.
IMPORTANT: Signature Approval
My signature below certifies that I have completed all of the above sections completely, accurately, and to the best of my knowledge and that I have read, understand, and agree to the terms of this enrollment form and the Authorization to Use and Disclose Health and Other Personal Information. If I am an active duty or retired military member, I commit to making the Compassionate Care Program aware, if at any time, I gain private insurance coverage for infertility treatment. If I am not an active duty or retired military member, I commit to making the Compassionate Care Program aware, if at any time, I gain any insurance coverage for infertility treatment. No units of product received under this program or any medical expenses related to my fertility treatment will be submitted for Medicare, Medicaid, TRICARE, the Department of Veterans Affairs, the Department of Defense, or any public or private third-party reimbursement, or returned for credit. Please remember that, as discussed above, your program eligibility requires that you promptly notify the Compassionate Care Program by calling (855) 541-5926 if you become insured by any private or government insurance plan.
Please only click the Submit button once. It may take several moments before it is completely submitted.
A representative will be in touch with you in 3 - 5 business days to inform you of the status of your application. Additional questions? Call 1-855-541-5926.
There was an error and has a code of 0. Please contact Trialcard at (855) 541-5926. Follow the prompts and let them know why you are calling. Be sure to write down the error code why your application was unsuccessful and provide this when you speak to the representative.
We apologize again for this inconvenience.