SuperBill Registration Form

SuperBill Registration

Please complete the form below
This option is for clients who would like to submit their own claims/billing. The superbill is created professionally using the official forms and contains all the coding and Provider information needed to submit your own claims successfully. You will be responsible for submitting the claim to your insurance Member Services. Superbills can only be created and submitted once your care with the Midwife is complete.
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 if your midwife is Not Listed.
CAUTION

If your midwife is not on our list, please contact us before submitting this form. You can find our contact us page by returning to our website: https://billingforlittles.godaddysites.com/. If your midwife is not listed, but you have already contacted us, PLEASE MAKE SURE TO UPLOAD YOUR MEDICAL RECORDS TO THE END OF THIS FORM.
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Due Date*

MonthDayYear
Date
Has your care already been completed, including your postpartum visit(s)?*

YesNo
Please note - commerical insurance will not accept superbills for prepayment. If your policy is a commerical insurance you will need to wait until care has been completed to submit claims.

If your insurance is a cost sharing platform like MediShare or Christian Health you may be able to submit claims for prepayment.

You are responsible for verifying if your insurance will accept claims for prepayment and submitting accordingly.

*If care has not been completed it is a claim for prepayment of services.
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
Do you have an insurance card?*

YesNo
Insurance Company*
Insurance Company State*
Insurance ID*
Typically referred to as Member ID or Policy #
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
File Upload (If your midwife is NOT LISTED, you MUST upload medical records here.)

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. I understand that this agreement 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.

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 necessary, 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*

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SuperBill Registration

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Insurance Information