My-IUD Supply

Proud to announce we currently accept most Florida Blue plans! We SPECIALIZE in Blue Cross/Blue Shield of Texas (most plans)!

Terms of usage

Practice/Physician Acknowledgement and Agreement with

  1. Complete the Online IUD Order/Referral Form as follows:
  2. Enter the patient and provider information in the space provided on the (IUD ORDER FORM), including the patient’s pharmacy drug benefit and medical insurance information.
  3. Please ensure that all information is complete • Include copies of the patient’s pharmacy benefits and medical insurance cards.
  4. Complete the ordering Provider information (complete this information and then photocopy the form for future use)
  5. Complete the IUD information section. • Indicate which IUD is to be ordered
  6. E-Sign the IUD Order/Referral Form by Checking the appropriate box
  7. Have the patient read and sign the Patient HIPPA Authorization section of the form. Also, have the patient check the acknowledgment of acceptance box on the online form. Please keep a copy of this form in the patients’ medical records.
  8. The IUD should arrive in 3-5 business days if the insurance benefits are verified, and coverage is active for the IUD prescribed.
  9. You agree to fill out an IUD POST INSERTION FORM on our Website after the specific IUD ordered is Inserted into the associated patient.
  10. You agree to bill the patient’s insurance for only for the IUD insertion fee and customary professional services only.
  11. I understand that the medical care agent for (GYN-Care, Inc.) will bill the patient’s Insurance for the reimbursement of the IUD ordered (J-Code).
  12. I understand that this order for an IUD may be considered a medical referral with a collaborating practice to supply the IUD for the patient and that the encounter with the patient from the ordering provider extends to My-IUD, LLC and its medical associates and providers.
  13. You agree that the IUD ordered and received was ordered only for that specific patient and that the specific IUD MUST NOT BE USED FOR ANY OTHER PATIENT!
  14. You agree that if the SPECIFIC IUD Ordered and RECEIVED is NOT PLACED into the patient that it was prescribed for within 30 days of delivery…that you will return the IUD back to, shipping labels and cost covered by
  15. The ordered IUD will be delivered by UPS signature only. You agree to take financial responsibility of the IUD once the IUD is signed for by your office personnel.
  16. If your practice does not return the specific unused IUD, then the practice agrees to pay for the retail price of the IUD.
  17. I agree that the person listed as signing the Provider Enrollment form is qualified to sign on behalf of the Practice group and will discuss the content with the other providers of the group.
  18. My-IUD, LLC, and its medical associates and providers, assumes no liability for claims and issues related to patient selection, IUD insertion, or complications arising from the clinical care of the patient.
  19. In order to order a Nexplanon, a provider for the practice must be trained and certified by Nexplanon and the certificate must be on file with In addition, the certified providers must be the inserting provider.
  20. does not allow for the return of any IUD/LARC in which the seal of the box  has been compromised or opened. This policy is in accordance with regulations set by the FDA.
  21. will swap or substitute an IUD or LARC as long as the seal has not been compromised or opened.
  22. I understand that due to any number of insurance related factors (network, deductibles, lack of coverage, etc.) that an order (referral) for an IUD may not be able to be fulfilled.
  23. I agree and acknowledge that the patient may then be eligible for a self-pay option to purchase her own IUD if she so chooses. (Medicaid, Medicare, and MCO patients are excluded)
  24. In these instances, I understand and agree that will offer the patient the option of purchasing her IUD on our affiliate website
  25. Once the patient purchases the IUD using will then ship the IUD to the referring practice for the patient’s insertion as per the above protocol.

IMPORTANT: Prescriber gives, and its medical associates and providers (GYN-Care, Inc.), express permission to use his/her NPI number included herein for the purpose of identifying the ordering provider to the authorized pharmacy/medical benefits manager and/or payer., and its medical associates and providers, 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.