Birth Control By Mail
Birth Control by Mail is one of the convenient ways to have your method
of birth control automatically sent to you.
Who can use this service?
Any established client of Family Planning Health Services (FPHS), who
is currently using birth control pills, Ortho Evra patches, Nuva Rings,
condoms, or other non-prescription products.
How do I sign up?
Just read and fill out the information below and mail to your local Family
Planning office. You only need to sign up once.
Why?
It saves you time and money!
-You can spend your time doing other things on your list instead of making
a ‘special trip’ to the clinic.
-You’ll have a steady supply of birth control available.
-Saves on gas, and wear & tear on your vehicle.
How do I pay?
We accept credit card (MC/Visa) Medical Assistance, Family Planning Waiver,
and can bill most prescription insurances (check with insurance to ensure
FPHS is a PPO with insurance). If paying with personal check or money
order, payment needs to be received prior to shipment.
What are the benefits?
-Confidentiality, as always.
Birth control supplies are sent to you in a return address envelope.
-We’ll notify you of upcoming visits you may need.
-Convenience! No travel, no appointments; you can plan ahead!
Website: www.fphs.org
1-800-246-5743
EC Hotline: 1-877-975-9858
Clinics in 7 counties: Adams, Juneau, Langlade, Lincoln, Marathon, Portage,
Taylor
(Call 800# for your local clinic)
Name____________________
Birth Date_________________
Mailing Address
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Phone (_____)______________
To use this service, I understand:
-FPHS will send me a 3-month supply of my birth control every 8-9 weeks,
or until its time for my next annual exam. FPHS may limit my birth control
supplies if follow-up services are needed.
For office staff only:
Date started: ______________
Any Follow-up needed: ____________
-I agree to pay bills that are my responsibility and maintain a zero
balance on my account. As long as I pay my bills, FPHS will mail me my
birth control! A 1-month supply will be sent to me if I have an outstanding
balance that is my responsibility.
-I will call FPHS if:
*I have a change in address
*I have any questions or problems
*My birth control does not arrive on time
-To discontinue this service, I will notify FPHS.
-If paying with personal check or money order, payment needs to be
received 1 week prior to shipment.
-I authorize payment from my Forward Card or my insurance on file.
-If paying with credit card (CC), I authorize FPHS to automatically deduct
my future birth control supply payments from my CC. If I no longer want
to use this CC or if my information changes, I will call FPHS.
CC: Visa, MC Exp date_____
CC acct#__________________
Signature__________________