Verification of Benefits Registration Form

Verification of Benefits Registration

Please complete the form below
This service determines your policy's coverage for the specific type of birth/care you are planning for and any limitations or exclusions in your plan.
We speak with a rep from your insurance and get details about your coverage for maternity care, including the place of birth you have planned, type of provider, and newborn care. If a gap request or prior authorization is applicable to your situation/provider, we will submit one as part of the verification process. We will email the verification to the email you provided.
You typically get a verification when you start your care with the midwife, but one can be done at any point. We recommend getting one before any billing so that you know what to expect for coverage.
Midwife Name*
If your midwife is Not Listed, we may not be able to complete your request. Please contact us first before submitting this form.
CAUTION

If your midwife is Not Listed, you must put the midwife name in the Additional Notes section. Also, please contact us before submitting this form and payment. We will need to make sure we can collect the necessary information about your midwife to complete the verification. You can find our contact page here - https://billingforlittles.godaddysites.com/contact
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Due Date*

MonthDayYear
Date
Phone Number
Email *
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Place of Birth Planned*
If you are undecided, please share which options you're considering in the Additional Notes field below.
Additional Notes
Please share any extra comments or concerns about your billing here.
Insurance Information
Insurance Company*
Insurance Company State*
Insurance ID*
Typically referred to as Member ID or Policy #
Last 4 digits of Social Security Number*
Last 4 digits of Social Security Number
Policy Holder's Name (if different than Patient)

First NameLast Name
Policy Holder date of birth, if different than Patient

MonthDayYear
Date
Insurance Card FRONT*

Cancelof
Insurance Card BACK*

Cancelof
I have additional insurance*

YesNo
Secondary Insurance Company
Secondary Insurance Company State
Secondary Insurance ID
Typically referred to as Member ID or Policy #
Secondary Insurance Policy Holder's Name, if different than Patient.

First NameLast Name
Secondary Insurance Policy Holder date of birth, if different than Patient

MonthDayYear
Date
Secondary Insurance Card FRONT*

Cancelof
Secondary Insurance Card BACK*

Cancelof
Consent to Bill, Privacy Notice and Fee Information Form

CONSENT FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION

I hereby authorize the Midwife Named Above (hereby referred to as Provider) to release any information acquired in the course of my examination and treatment to Lyons Medical Billing LLC, for the purposes of insurance verification and billing. I authorize the release of medical information to my insurers as necessary for the determination and payment of benefits.

TERMS OF THE PROVIDER’S FINANCIAL AGREEMENT

I understand that I am responsible for any part of the medical charges that are not covered/paid by my insurance, and I will be billed directly for those services by the Provider, according to the financial agreement I have with them. I understand that this agreement for insurance billing does not affect the fee schedule or amounts due to the Provider in their financial agreement with me, but that insurance payment will be a reimbursement.

PRIVACY NOTICE

Lyons Medical Billing LLC abides by a HIPAA compliant Business Associates Agreement with the Provider and does not share data with any other parties besides the Provider and your insurance company for the purpose of obtaining payment. I have received the privacy policy from the Provider.

This form is compliant with HIPAA standards. It is my responsibility to use it with a secure devce/internet connection for privacy.

REIMBURSEMENT

I understand that my insurance will be billed for the full amount of any charges I have coverage for, regardless of how much I have paid the Provider. I understand that if a payment is sent from my insurance, I am due only a refund up to the amount I paid, and anything greater will be remitted to the Provider. If my insurance sends the payment to me directly, I will notify Lyons Medical Billing and the Provider of the amount and provide the Explanation of Benefits included with the payment. If neccessary, I will cooperate in dividing the amount according to my financial obligations, which will be calculated by Lyons Medical Billing according to the benefits of my policy and the charges of the Provider.
Signature*

Powered by Jotform SignClear
My Products*
prevnext( X )
Verification of Benefits
$35.00 Quantity

Total

$0.00
Should be Empty:

Verification of Benefits Registration

CAUTION

Insurance Information