MIDWIVES ADVANTAGE
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MIDWIFE INFO
Midwife Clients
Verify Insurance Benefits
Information After Claims Are Filed
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Indicates required field
Choose Your Midwife's Claims Manager.
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CHOOSE MIDWIFE'S CLAIMS MANAGER
BETHANY
FAITH
GABBY
HOPE
NORA
WHITNEY
ESTIMATED DUE DATE
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NAME OF MIDWIFE
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PATIENT FULL NAME
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Patient Phone Number
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Patient's email address
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Patient Date Of Birth MM/DD/YYYY
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Social Security Number
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Date Of Last Period MM/DD/YYYY
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Estimated Due Date MM/DD/YYYY
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Name Of Insurance Company
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Member ID
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Group Number
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INSURANCE PHONE NUMBER
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Policy Holder's Full Name
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First
Last
Policy Holder Date Of Birth MM/DD/YYYY
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Policy Holder's Address (use two letter abbreviation for state and USA for country)
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Line 1
Line 2
City
State
Zip Code
Country
PATIENT'S RELATIONSHIP TO POLICY HOLDER
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SELF
SPOUSE
CHILD
OTHER
Policy Holder's Place Of Employment
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DOES PATIENT HAVE 2ND INSURANCE?
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NO
YES
UNSURE
Secondary Insurance Info (policy holder's name, DOB, relationship to patient, member ID, Group ID, insurance name/number)
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Photo Of Insurance Card (Front)
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Max file size: 20MB
Photo Of Insurance Card (Back)
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Max file size: 20MB
PHOTO OF 2ND INSURANCE CARD (FRONT)
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Max file size: 20MB
PHOTO OF 2ND INSURANCE CARD (BACK)
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Max file size: 20MB
HAS ANYTHING BEEN SUBMITTED TO YOUR INSURANCE FOR THIS CARE?
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No, nothing has been sent to my insurance.
Yes, documents or a claim has been sent my insurance.
DATE OF NEXT APPOINTMENT
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Comment
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Submitting this form constitutes agreement with our Terms of Agreement. Terms are explained via Docusign which will open after you submit this form.
Submit
Insurance benefit details will be sent to your midwife via Basecamp
.
Home
About Us
Our Advantage
CONTRACT
SCHEDULE A CALL
MIDWIFE INFO
Midwife Clients
Verify Insurance Benefits
Information After Claims Are Filed
Blog