Midwife Client Insurance Information

This form is to verify insurance coverage for people using a midwife or birth center and that provider will later file your claims with us. If your midwife doesn't accept insurance and you need our assistance submitting your own insurance claim, do not complete this form. Go to Midwife Doesn't Take Insurance.

SEND TO ACCOUNT MANAGER *

* Indicates required field

Name Of Midwife *

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 *

Date Of Last Period MM/DD/YY *

Estimated Due Date MM/DD/YY *

Name Of Insurance Company *

Member ID *

Group Number *

MEMBER PHONE NUMBER TO CALL INSURANCE *

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

Submit

Please sign patient agreement. This link takes you to Docusign.

PATIENT AGREEMENT TO BILL CLAIMS

Patient Insurance Information

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