MIDWIVES ADVANTAGE
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Information After Claims Are Filed
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Your Midwife's Claims Manager
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GABBY
*
Indicates required field
VERIFICATION REQUEST STATUS
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INITIAL REQUEST
UPDATE MY INSURANCE INFORMATION
Estimated Due Date MM/DD/YYYY
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MIDWIFE'S FIRST AND LAST NAME
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PATIENT FULL NAME
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Patient Phone Number
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Patient's email address
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Patient Date Of Birth MM/DD/YYYY
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Social Security Number
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Date Of Last Period MM/DD/YYYY
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Name Of Insurance Company
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Member ID
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Group Number
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INSURANCE PHONE NUMBER
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Policy Holder's Full Name
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First
Last
Policy Holder Date Of Birth MM/DD/YYYY
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Policy Holder's Address (use two letter abbreviation for state and USA for country)
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Line 1
Line 2
City
State
Zip Code
Country
PATIENT'S RELATIONSHIP TO POLICY HOLDER
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SELF
SPOUSE
CHILD
OTHER
Policy Holder's Place Of Employment
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DOES PATIENT HAVE 2ND INSURANCE?
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NO
YES
UNSURE
Secondary Insurance Info (policy holder's name, DOB, relationship to patient, member ID, Group ID, insurance name/number)
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Photo Of Insurance Card (Front)
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Max file size: 20MB
Photo Of Insurance Card (Back)
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Max file size: 20MB
PHOTO OF 2ND INSURANCE CARD OR PHOTO ID
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Max file size: 20MB
PHOTO OF 2ND INSURANCE CARD (BACK) OR PHOTO ID
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Max file size: 20MB
HAS ANYTHING BEEN SUBMITTED TO YOUR INSURANCE FOR THIS CARE?
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No, nothing has been sent to my insurance.
Yes, documents or a claim has been sent my insurance.
DATE OF NEXT APPOINTMENT
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Comment
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Adobe Sign will open after you submit this form. Once agreement is signed, this form will be processed and the results will be made available online to your midwife.
Submit
Insurance benefit details will be sent to your midwife via Basecamp
.
Home
About Us
Our Advantage
GET INFO
Q&A
Midwife Clients
Verify My Insurance
Information After Claims Are Filed
Blog