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Verification of Benefits
Our verification service includes: Personally calling your insurance company and verifying your benefits, obtaining any authorizations or referrals. We will request in-network coverage for out of network providers when available, if the exception is granted, the services will be reimbursed at the in-network level.
Email address *
Today's Date *
MM/DD/YYYY
Your answer
Name *
First Middle Last
Your answer
Address Line1 *
Your answer
Address Line 2
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone Number *
Your answer
Email *
Your answer
Martial Status *
Date of Birth *
MM/DD/YYYY
Your answer
First Time Pregnant? *
Due Date *
MM/DD/YYYY
Your answer
Last Menstrual Period *
MM/DD/YYYY
Your answer
Desire Place of Birth *
Choose more than one if undecided
Required
Insurance Information
(Dont write anything here)
Your answer
Primary Insurance Company *
Your answer
Name of Plan
Your answer
Insurance Company Address Line 1
Where to send claim
Your answer
Insurance Company Type
Insurance Company Address Line 2
Your answer
Ins Co City
Your answer
Ins Co State
Your answer
Ins Co ZIP
Your answer
Ins Co. Phone Number *
Your answer
Subscriber Name *
First Middle Last (if married and spouse main holder please put their name here
Your answer
Subscriber Date of Birth (DOB) *
MM/DD/YYYY
Your answer
Subscriber's Social Security *
xxx-xx-xxxx
Your answer
Patient's Social Security *
xxx-xx-xxxx
Your answer
Member ID on the card *
if you have copy of card please fax to (813) 365-3074
Your answer
Group Number on the card
Your answer
Employer's Name
(If insurance through an employer)
Your answer
Relationship to Subscriber *
Provider Information
Dont write anything here
Your answer
Provider Name
First Last Name
Your answer
Provider Company Name
Your answer
Provider Address Line 1
Your answer
Provider Address Line 2
Your answer
Provider Address City
Your answer
Provider Address State
Your answer
Provider Address ZIP
Your answer
Provider Phone Number
Your answer
Provider Email
Your answer
Would you like us to foward your benefits information to your provider *
I authorize Childbirth Options Midwife Billing to obtain my insurance benefits *
Required
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
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