Verify Insurance Benefits

* Indicates required field

Choose Your Midwife's Claims Manager. *

ESTIMATED DUE DATE *

NAME OF MIDWIFE *

PATIENT FULL NAME *

Patient Phone Number *

Patient's email address *

Patient Date Of Birth MM/DD/YYYY *

Social Security Number *

Date Of Last Period MM/DD/YYYY *

Estimated Due Date MM/DD/YYYY *

Name Of Insurance Company *

Member ID *

Group Number *

INSURANCE PHONE NUMBER *

Policy Holder's Full Name *

First

Last

Policy Holder Date Of Birth MM/DD/YYYY *

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

HAS ANYTHING BEEN SUBMITTED TO YOUR INSURANCE FOR THIS CARE? *

DATE OF NEXT APPOINTMENT *

Comment *

Submitting this form constitutes agreement with our Terms of Agreement. Terms are explained via Docusign which will open after you submit this form.

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Insurance benefit details will be sent to your midwife via Basecamp.

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Empowering Midwifery Education has a series of educational courses devoted to midwives and being entrepreneurs in today's fast paced health care system. Look through our series of great courses to learn about tax savings, accounting, policy creating, starting a home birth practice, starting a birth center practice, marketing, and so much more!

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Patient Verification ​of Benefits

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Patient Verification
of Benefits