New Claim Submission

Name of Primary Midwife *

First Name

Last Name

Phone *

(###)

###

####

Office Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client/Patient Name

First Name

Last Name

Name of Primary Insurance Holder

if different than client ex: client's partner

First Name

Last Name

Client/Patient DOB *

MM

DD

YYYY

Client/Patient's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client/Patient Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

LMP *

MM

DD

YYYY

EDD *

MM

DD

YYYY

Midwife Arrival Time (enter 0 for seconds) *

Hour

Minute

Second

AM PM

Midwife Departure Time (enter zero for seconds) *

Hour

Minute

Second

AM PM

Birth Setting *

Planned Home Birth

Birth Center

Planned Hospital Birth with primary midwife

Hospital Birth with transfer to hospital staff/OB

Date of 1st Prenatal Visit *

MM

DD

YYYY

Non Stress Test

MM

DD

YYYY

Rhogam: mini dose

MM

DD

YYYY

Rhogam: full dose

MM

DD

YYYY

Birth

Induction of Labor

TOLAC/VBAC

Vaginal Birth

Vacuum Assisted

Forceps Assisted

Cesarean Birth

Aquatherapy

Yes

No

Other Licensed Provider

Complete if the above complications were assisted by a licensed provider other than the primary birth attendant.

First Name

Last Name

Transport to Hospital

Yes

No

Newborn's Date of Birth *

MM

DD

YYYY

Time of Birth

Hour

Minute

Second

AM PM

Date of 1st Postpartum Visit

MM

DD

YYYY

Attestation *

I understand that Birth Professional Billing utilizes encrypted data storage. I understand that I am responsible for the secure submission of this information and am submitting this data through a secure connection on a secure device.

Primary Midwife's Name *

First Name

Last Name

Client/Patient Name *

First Name

Last Name

Client/Patient Date of Birth *

MM

DD

YYYY

Name of Primary Insurance Holder *

First Name

Last Name

EDD *

MM

DD

YYYY

Newborn's Full Name *

First Name

Last Name

Newborn's Date of Birth *

MM

DD

YYYY

Time of Birth *

Hour

Minute

Second

AM PM

Place of Birth *

Planned Home Birth

Birth Center

Planned Hospital Birth with Primary Midwife

Hospital Birth with transfer of care to hospital staff or OB.

Address of Birth Location

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Was resuscitation needed after birth? *

Yes

No

Date of Initial Newborn Exam

If hospital staff is billing for initial NB exam, please leave blank.

MM

DD

YYYY

Date of Well Baby Visit *

MM

DD

YYYY

Newborn Screen *

Yes, collected at well baby visit.

Not obtained by midwife.

Date of Vitamin K Administration

Leave blank hospital pediatric staff administered Vitamin K.

MM

DD

YYYY

Date of Newborn Hearing Screen

Leave blank if hospital pediatric staff performed screen.

MM

DD

YYYY

Attestation *

I understand that Birth Professional Billing utilizes encrypted data storage. I understand that I am responsible for the secure submission of this information and am submitting this data through a secure connection on a secure device .