Insurance Verification & Consent Form for Classes
By completing this form, you are giving My Pure Delivery permission to contact your insurance provider to verify benefits as well as authorizing My Pure Delivery to bill for classes attended.
Mother's Name *
Mother's Date of Birth *
MM
/
DD
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YYYY
Mother's phone number *
Home Address *
Primary Insured Name *
Primary Insured's Date of Birth *
MM
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DD
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YYYY
Which insurance provider does (expectant) Mother have? *
Subscriber Number/ Member ID *
Group Number *
Is your plan a ... *
Required
Phone number for Provider Services (on back of card) *
I grant permission to My Pure Delivery to bill my insurance carrier(s) for services rendered. I understand that I will owe My Pure Delivery for any insurance payments made to me directly. *
Required
I assign my insurance benefits to be paid directly to Diba Tillery or Babies 411 LLC DBA My Pure Delivery. If insurance reimbursements are paid to me instead of the provider, I understand that it is not lawful to retain insurance reimbursement rightly due to the provider. In the event that I do retain any insurance reimbursements due to My Pure Delivery, all litigation and attorney fees to recoup such insurance reimbursement will be borne by me. *
Required
Release: I authorize My Pure Delivery to release any private health information acquired to my insurance company. *
Required
Submit
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