Verification of Benefits

Step 1: Fill in Form Completely
Step 2: Submit Completed Form
Step 3: Make Payment on Payment page. $55 primary policy, and $40 for a secondary policy
Step 4: Email Copy of Insurance Card

Please email a copy of the front and back of your insurance card to margaret@innovativemedicalbillinginc.com The easiest way is to take a photo with your phone and email it.

Expectant Parent's Information
Name:* Gender / Preferred Pronouns: Address:* City:* State:* Zip Code:* Day Phone: Evening Phone:* E-mail: *Marital Status: Date of Birth: Age:** First Pregnancy?* Due Date:* Date of Last Menstrual Period: Preferred Place of Birth: Concurrent Care: Yes No

Information about Your Midwife or Provider
Name of your Midwife or Provider:* Address: City:* State:* Zip Code:* Phone Number:* E-mail: Forward your information to your midwife or provider?*

Information about your Insurance Company
Primary Insurance Company:* Plan Name: Insurance Company Address: City: State: Zip Code: Insurance Company Phone:* Subscriber's Name:* Subscriber's Gender / Preferred Pronouns: Subscriber's Date of Birth:* Subscriber's SSN: Id Number from Card:* Group Number from Card:* Member's Relationship to Subscriber:*

Secondary Insurance Company:
Plan Name:
Insurance Company Address: City: State:
Zip Code:
Phone Number:
Subscriber's Name:
Subscriber's Date of Birth:
Subscriber's SSN:
ID Number:
Group Number:
Member's relationship to Subscriber:

Member's Signature
Today's Date:

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