Background: As survival of patients with hematologic malignancies improves, quality of life (QOL) measures have gained importance. Cancer therapies can have a deleterious impact on fertility in patients of childbearing age. Previous studies have highlighted disparities in access to oncology care in rural patients, with negative effects on health outcomes and QOL. This study aims to explore the impact of rurality on fertility preservation in adult young adult (AYA) population. Methods: The study examined patients with a new diagnosis of acute leukemia or lymphoma, ages 15-39, between 2017-2022 at the University of Vermont Medical Center. These included Acute lymphoblastic leukemia (ALL), Acute myeloid leukemia (AML), Hodgkin’s lymphoma, and Non-Hodgkin’s lymphoma. We identified 145 patients and collected data on demographics, insurance, zip codes, cancer diagnoses and whether referral to fertility preservation was requested. Rurality was determined using United States census data, with Rural-Urban Commuting Area (RUCA) codes 1-3 considered urban, and codes 4-10 being considered rural. Results: Of the 145 patients, majority resided in rural (N = 81 or 56%) as compared to urban areas (N = 64 or 44%). Majority of patient did not receive a referral for discussion of fertility preservation (N = 77 or 53%). Of the patients that were referred, more urban patients received referrals (N = 38 or 56%), compared to rural cancer patients (N = 30 or 44%), and this difference was statistically significant (OR = 2.5, 95% CI 1.2-5.14, p = 0.0074). The type of insurance the patient had impacted referral rates. Patients with private insurances were more likely to receive a referral compared to those who had no insurance or had Medicare/Medicaid, (N = 41 or 60% vs. N = 27 or 40%) and this difference was also statistically significant (OR = 2.13, 95% CI 1.04-4.38, p = 0.0243). Conclusions: We find that rural AYA patients with hematologic malignancies were less likely to receive referral for fertility preservation, compared to their urban counterparts. Patients with private insurances had the highest rates of referrals, while patients with Medicare/Medicaid or no insurance were less likely to be referred. This study highlights disparities in access to fertility preservation in rural cancer patients, with significant potential impact on quality of life.