UIRC Bridge Program Application
The UIRC Referral program is designed to serve individuals seeking infertility counseling by qualified therapists who want to access services using their private insurance coverage but need a financial bridge to do so. At this time we are only able to see individuals who are insured by EMI, Blue Cross Blue Shield, Regence, PEHP, University of Utah Health Plans and UNI BHN.

There are a few things that you will need to gather prior to completing this application:

1. Contact your insurance company and ask them the following questions.(Typically you can find their phone number on the back of your insurance card)
a. What is my mental health deductible? Has it been met?
b. What is the contracted rate for an in-network therapist for the CPT codes 90791 and 90837?
c. What is my out of pocket cost for a session using the codes listed above? For example, do I need to meet the deductible before insurance will help share the cost? Or, just a co-pay? And, if it's co-pay only, what is that cost?

2. Your household gross income.

In order to qualify for the bridge program all questions on the application need to be completed.

Name *
Your answer
Name of your insurance company *
Your answer
What is your mental health deductible? How much of that cost has been met at this date? *
Your answer
Once your mental health deductible has been met, what will your out of pocket cost be? *
Your answer
What is your out of pocket cost for CPT code 90791 with an in-network provider? (if you don't know this, please call your insurance company to inquire) *
Your answer
What is your out of pocket cost for CPT code 90837 with an in-network provider? *
Your answer
What is your annual net family income? *
Your answer
Which therapist would you like to see? *
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