JORDYN ZMOLIK

This form doesn't obligate you or your midwife to file claims with us.
Complete information helps us obtain the most accurate coverage of your policy.

* Indicates required field

VERIFICATION REQUEST STATUS *

FIRST REQUEST I NEED TO UPDATE MY INSURANCE INFORMATION

PATIENT FULL NAME INCLUDING MIDDLE INITIAL (AS STATED ON INSURANCE CARD) *

Patient Date Of Birth MM/DD/YYYY *

Social Security Number (last four digits) *

PATIENT ADDRESS (use two letter abbreviation for state and USA for country) *

Line 1

Line 2

City

State

Zip Code

Country

Patient Phone Number *

Patient's email address *

BIRTH CENTER OR PROVIDER NAME *

YOU MIGHT BE ON YOUR OWN POLICY, YOUR SPOUSE'S POLICY AND YOUR PARENTS POLICIES. IT IS IMPORTANT FOR US TO HAVE INFORMATION ON EVERY POLICY YOU ARE COVERED BY. HOW MANY INSURANCE POLICIES DO YOU HAVE? *

COMPLETE A SEPARATE FORM FOR EACH INSURANCE POLICY. WHICH POLICY IS THIS INFORMATION FOR? *

Date Of Last Period MM/DD/YYYY *

ESTIMATED DUE DATE MM/DD/YYYY *

PATIENT'S RELATIONSHIP TO PRIMARY SUBSCRIBER *

NAME OF PRIMARY INSURANCE SUBSCRIBER *

DATE OF BIRTH OF PRIMARY INSURANCE SUBSCRIBER *

ADDRESS OF PRIMARY INSURANCE SUBSCRIBER IF DIFFERENT THAN PATIENT ADDRESS *

Line 1

Line 2

City

State

Zip Code

Country

NAME OF INSURANCE *

MEMBER ID NUMBER *

GROUP NUMBER *

IMPORTANT DOCUMENT NEEDED**. LOGIN TO YOUR PATIENT PORTAL OR CALL THE HR DEPARTMENT OF THE EMPLOYER THAT OFFERS THE INSURANCE AND ATTACH A COPY OF YOUR SUMMARY PLAN DESCRIPTION (SPD) OR SUMMARY OF BENEFITS AND COVERAGE BELOW. *

Max file size: 20MB

INSURANCE CARD - FRONT *

Max file size: 20MB

INSURANCE CARD - BACK *

Max file size: 20MB

DRIVERS LICENSE OR ID CARD *

Max file size: 20MB

COMMENT *

Submit

When you're ready, click the Submit button. This will redirect you to Adobe Sign, a platform where you can authorize your midwife as your insurance's Authorized Representative. This authorization lets us communicate with your insurance company if we file your claims.

We apologize for the repetitive fields on this page and the authorization document. Please complete all fields accurately so your claims are processed promptly. Midwives Advantage will not send your insurance company the Terms of Agreement (the last page). We included it to clarify items that other parents have had questions about.

We wish you the best during your pregnancy and birth!

We will send your insurance benefits to your midwife.

​JORDYN ZMOLIK

JORDYN ZMOLIK