2 Insurance Verification — Birth Professional Billing

INSURANCE VERIFICATION FORM

PLEASE READ THIS PRIOR TO SUBMITTING THE VERIFICATION OF BENEFITS FORM!

The midwife/center you are working with has a flat fee that they charge their clients and they require that this fee is paid by a certain date. Each practice is different so you will need to check with your provider for those details. The flat fee is a package price that includes many different scenarios and is deeply discounted because it does not require the use of a medical biller. If you utilize your health insurance, we have to bill the insurance for services rendered. This means sometimes what is billed to the insurance is more than the flat fee and sometimes it will be less. The flat fee does not correlate with the amount billed to the insurance. The flat fee will count as a retainer towards your patient responsibility (deductible, coinsurance, etc.). If your patient responsibility is less than the flat fee you will be reimbursed the difference minus the billing fee of 10%.

By submitting this verification of benefits I am agreeing to utilize the services of Birth Professional Billing to file the insurance claim after services are rendered. I AM CONSENTING TO BIRTH PROFESSIONAL BILLING'S FEE OF 10% OF THE PAYMENT FROM MY INSURANCE COMPANY.

Have you (person receiving maternity care) delivered? YES/NO

Patient (person receiving maternity care)

First Name

Last Name

Patient Date of Birth

MM

DD

YYYY

Email Address

Name of Practice/Midwife/Birth Center

Insurance Company

Insurance ID Number

Insurance Company Phone Number

(###)

###

####

Expected date at 40 weeks of pregnancy/Due date

MM

DD

YYYY

Name & Date of birth of primary insurance holder if different from above.

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Comments

Attestation

By submitting this form, I consent to sharing my personal health information with Birth Professional Billing and am consenting to an insurance verification process.

I give my consent for Birth Professional Billing to contact my insurance company and discuss the above information including confidential health information.

I understand that Birth Professional Billing utilizes encrypted data storage but that use of electronic communication may be vulnerable to data breeches and I am using a secure connection on a secure device to submit this information.

Based in North Carolina, Birth Professional Billing was founded by a midwife who understands the demands of working with clients & insurance companies to obtain payment for services. WE’re here for you.

INSURANCE VERIFICATION FORM

PLEASE READ THIS PRIOR TO SUBMITTING THE VERIFICATION OF BENEFITS FORM!

Birth Professional Billing is dedicated to obtaining the highest level of reimbursement for you and your clients. we understand your work & offer our deepest commitment to your billing services.

by Marketing + Wellness