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    Would you like to know whether your insurance covers and reimburses midwifery services? We are happy to verify insurance benefits for anyone seeking midwifery care. For a $20 fee, we will call and verify your insurance benefits, obtain any necessary referrals or authorizations and request an in-network exception for out-of-network providers. If the exception is granted, the services will be reimbursed at the in-network rate, regardless of whether your midwife is contracted with your insurance company. Please fill out the form below; we will respond within four working days with your verification.

    MIDWIFE Billing & Business, LLC

    Request for Verification of Insurance Benefits

    MEMBER INFORMATION

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    Name (Last, First, MI)*
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    Today's Date*
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    Address*
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    City*
    State*
    Zip Code*
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    Evening Phone
    Daytime Phone
    Email
    Marital Status
    Birthdate*
    Age
    First Pregnancy?*
    Due Date*
    Date of Last Menstrual Period (LMP)*
    MIDWIFE INFORMATION

    Name of Your Midwife*
    Address*
    City*
    State*
    Zip Code
    Phone Number*
    Email
    Do you want us to forward your benefit information to your midwife?*
    INSURANCE INFORMATION
    Primary Insurance Company*
    Plan Name
    Insurance Company Address
    City
    State
    Zip Code
    Insurance Co. phone (usually on the back of your card)*
    Subscriber's Name*
    Subscriber's Date of Birth*
    Subscriber's SSN #
    ID# on Card*
    Group # on Card*
    Member's Relationship To Subscriber*
    Secondary Insurance Company
    Plan Name
    Insurance Co. Address
    City
    State
    Zip Code
    Insurance Co. phone (usually on the back of your card)
    Subscriber's Name
    Subscriber's Date of Birth
    Subscriber's SSN
    ID# on Card
    Group# on Card
    Member's relationship to Subscriber
    AUTHORIZATION

    I authorize MIDWIFE Billing & Business, LLC and their representatives to discuss my health information with my insurance company as it pertains to insurance coverage for midwifery care. I understand this information is protected by law and will be kept confidential. IF YOU AGREE, PLEASE CLICK ON THE "I AGREE" BUTTON BELOW AND TYPE IN YOUR NAME. By clicking on the "I AGREE" button below and typing in your name, you agree that you have read and you understand the terms and conditions set forth above.

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    Member's signature*
    Date*
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    I Agree