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FMBS Patient Insurance Submission Birth Center & Midwife for Mom & Baby Form
1
Image Field
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2
Sender
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3
What is the FIRST and LAST name of the Patient?
*
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First Name
Last Name
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4
Patient Email
*
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example@example.com
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5
I Acknowledge - select all that apply
*
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My provider is Out of Network and my claim may not reimburse IF my plan is an HMO/EPO/POS
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6
I Acknowledge - select all that apply
*
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FMBS is unable to assist with claim follow up after submission due to my provider being OON
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7
I would like to....
*
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Move Forward with Billing
Request a Refund
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8
What service are you submitting for?
*
This field is required.
Mother & Infant Care $125.00
Birth Center & Midwife for Mother/Infant $200.00
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9
What is today's date?
*
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-
Month
Day
Year
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10
What is a good email for you? (the submitter)
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11
What is the Patient's date of birth?
*
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-
Month
Day
Year
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12
What is your address?
*
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Street Address
City, State and Zip
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13
What is a good phone number?
*
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14
What is the name of your Midwife?
*
This field is required.
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15
What is your Insurance Plan Name?
*
This field is required.
(ie..Aetna)
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16
What is your Member/Policy ID #?
*
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17
Send us a FRONT picture of your insurance card (pdf, png, jpeg, jpg ONLY)
*
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Max. file size
: 1.0MB
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18
Send us a BACK picture of your insurance card (pdf, png, jpeg, jpg ONLY)
*
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Max. file size
: 10.6MB
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19
Where did you receive your prenatal care?
*
This field is required.
Please Select
Home 12
Office 11
Birth Center 25
Please Select
Please Select
Home 12
Office 11
Birth Center 25
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20
What was the approximate date of your FIRST prenatal appointment?
*
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-
Month
Day
Year
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21
What was the approximate date of your LAST prenatal appointment?
*
This field is required.
-
Month
Day
Year
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22
Did your Midwife provide prenatal care AND deliver your baby?
*
This field is required.
Yes, 59400 dx O80 Z370
No, 59426 dx Z3491
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23
Where did you deliver your baby?
*
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Please Select
Home 12
Office 11
Birth Center 25 - Bill Facility for delivery date 0724/59409
Please Select
Please Select
Home 12
Office 11
Birth Center 25 - Bill Facility for delivery date 0724/59409
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24
What date did you deliver your baby?
*
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-
Month
Day
Year
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25
Did you labor at the birth center before you delivered?
*
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No
Yes, Labor Facility 0724 with 99236 dx O63.9
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26
List all the days you labored at the facility but did not give birth.
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27
Did you stay at the birth center AFTER you delivered?
*
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No
Yes, PP Facility 0724 with 99236 dx Z39.0
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28
List all the days you stayed at the birth center after your delivery.
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29
Did you receive lactation care?
*
This field is required.
No, no lactation care billable
Yes, bill 99214 / 99403/ S9443 dxZ391
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30
List All the dates you received lactation care?
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31
What is the baby's FULL name?
*
This field is required.
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32
What is baby's date of birth?
*
This field is required.
-
Month
Day
Year
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33
What is the baby's gender?
*
This field is required.
Please Select
female
male
X
Please Select
Please Select
female
male
X
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34
Did baby receive care from the midwife?
*
This field is required.
No
Yes, 99203 dx Z00129
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35
What date did baby first receive care?
-
Month
Day
Year
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36
Did baby receive follow wellness/lactation care?
*
This field is required.
No
Yes, 99213/99403 dx R6330
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37
List all the dates baby received follow up care
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38
Provide your Total Amount Paid for care & Related Notes
*
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39
Related Attachments
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Max. file size
: 10.6MB
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40
Terms and Conditions
*
This field is required.
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41
Our deepest apologies that we were unable to assist. Insurance plans have made it quite difficult for us to truly assist our out of network providers. A refund will be issued
*
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FMBS Patient Insurance Submission Birth Center & Midwife for Mom & Baby Form | Favored Medical Billing
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