Midwife Client Insurance Information

This form gives us the information to verify your insurance coverage for out-of-hospital birth. Please read our Information page for Parents so you understand how our company works.
*This form is for people using a midwife or birth center and that provider will later file your claims with us.

USE CAP LOCK
CHOOSE CORRECT ACCOUNT MANAGER (please ask your midwife the name of her account manager)
LIST YOUR MIDWIFE'S FIRST AND LAST NAME. DO NOT INCLUDE CREDENTIALS.

SEND TO ACCOUNT MANAGER *

* Indicates required field

Name Of Midwife (FIRST AND LAST NAME ONLY) *

First

Last

Name Of Patient *

First

Last

Patient Phone Number ( only for insurance information) *

Patient Email *

Patient Date Of Birth MM/DD/YY *

Social Security Number (last four digits) *

Date Of Last Period MM/DD/YY *

Estimated Due Date MM/DD/YY *

Name Of Insurance Company *

Member ID *

Group Number *

INSURANCE PHONE NUMBER *

Policy Holder's Full Name *

First

Last

Policy Holder Date Of Birth MM/DD/YY *

Policy Holder's Address (use two letter abbreviation for state and USA for country) *

Line 1

Line 2

City

State

Zip Code

Country

PATIENT'S RELATIONSHIP TO POLICY HOLDER *

Policy Holder's Place Of Employment *

DOES PATIENT HAVE 2ND INSURANCE? *

Secondary Insurance Info (policy holder's name, DOB, relationship to patient, member ID, Group ID, insurance name/number) *

Photo Of Insurance Card (Front) *

Max file size: 20MB

Photo Of Insurance Card (Back) *

Max file size: 20MB

PHOTO OF 2ND INSURANCE CARD (FRONT) *

Max file size: 20MB

PHOTO OF 2ND INSURANCE CARD (BACK) *

Max file size: 20MB

HAS ANYTHING BEEN SUBMITTED TO YOUR INSURANCE FOR THIS CARE? *

Comment *

Submit

FORMS TAKE A WHILE TO PROCESS, PLEASE ONLY CLICK SUBMIT ONCE. THANK YOU!

Please click on the link below to access the patient agreement via Docusign. This agreement does not obligate you or your midwife to file claims through us but informs you of our policies in the event your claims are filed with us. If you have any concerns or questions regarding the Agreement to Bill, please contact us! After we receive your insurance information, you and your midwife will receive an email with the details of your coverage. Together, we can experience success in billing your insurance for your care with a midwife. Congratulations on choosing a midwife for your birth journey!

PATIENT AGREEMENT TO BILL CLAIMS

What Midwives Are Saying

We were paid quickly and our clients were able to finance their birth with my practice through insurance. Thank You Midwives Advantage!"

"I've used all the billers for my claims! Midwives Advantage is definitely the best!"

"At first, I thought this was too good to be true but decided to give it a try. I really couldn't see that I had anything to lose by submitting a few claims from births that I'd already done. My clients were all for it! I got my first payment a month later, and I've never looked back. I really can't thank you enough for all you've done for my clients and me. It is such a relief to have a solution to offer my clients that have insurance!"

"This company is one of those things in life that almost seems too good to be true! I've been with Midwives Advantage for six years, and although they've had some struggles with some payers, I can say they never stopped working on claims. These women don't stop. They are constantly improving. I've seen a lot of changes over the years, and it just continues to amaze me. I am so happy to be able to give care to my clients and know I have responsive experts handling the insurance claims. Thank you for all you've done, and you continue to do for midwives!"

"My midwife emailed me and told me about Midwives Advantage. I submitted my insurance information, and she submitted the information for my claims. Imagine my surprise when all the claims were paid within 30 days! This was my fourth home birth with the same insurance and the only one that my insurance paid for! What your company is doing for the birth community is amazing. You guys are worth your weight in gold! Thank you!"

Midwife Request for information

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