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
Have you started care with the Midwife?

YesNo
Are you currently pregnant?

YesNo
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.

Purpose of Verification of Benefits
I understand that Verification of Benefits (VOB) is an informational service used to help gather insurance plan details such as out-of-network benefits, deductibles, coinsurance, and claim submission requirements. VOB results are based on information provided verbally, electronically, or in writing by my insurance company at the time of verification.

No Guarantee of Coverage or Payment
I understand and agree that:

VOB information is not a guarantee.
Insurance companies may provide inaccurate, incomplete, or conflicting information. Benefits quoted during verification may change, be applied differently, or be denied when a claim is processed.
Coverage decisions are made by the insurance company, not Lyons Medical Billing or the Provider.
Lyons Medical Billing does not guarantee insurance coverage, reimbursement, claim approval, or payment amount.
The insurance company determines the final outcome.
The final determination of medical necessity, covered services, allowable amounts, and reimbursement is made only when the insurance company processes the claim.
Out-of-network billing has additional uncertainty.
Because my Provider is out-of-network, reimbursement may be reduced or denied even if benefits appear to exist.

Patient Responsibility
I understand that it is my responsibility to:

review my insurance plan documents, Summary of Benefits, and exclusions
confirm out-of-network maternity coverage directly with my insurance company if desired
understand that my plan may include restrictions, exclusions, or special requirements (such as preauthorization, medical necessity review, claim filing limits, or documentation requirements)
I understand I am financially responsible for all fees charged by my Provider according to the Provider’s Financial Agreement, regardless of insurance payment or benefit verification results.

Limitations of Verification of Benefits
I understand that Verification of Benefits may not capture all plan limitations, including but not limited to:

plan exclusions (including maternity exclusions or home birth exclusions)
network exceptions or gap exceptions
retroactive plan terminations or changes
coordination of benefits issues
medical necessity requirements
claim processing errors or payer interpretation
employer plan rules that override standard benefits

Acknowledgment
By signing below, I acknowledge and agree that I remain financially responsible for the Provider’s full fee regardless of insurance coverage or reimbursement.
Signature*

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Verification of Benefits Registration

CAUTION

Insurance Information