Insurance Verification - Rooted Birth

Insurance Verification

Complete this information, upload copies of your insurance card, and pay the $25 fee to register with Loudon Business Solutions. The biller will verify your coverage and options and contact you with details. Please note that verification of out-of-network benefits is not a guarantee of payment by the insurance company. All clients are responsible for payment in full to Rooted Birth Midwifery & Wellness by 36 weeks, regardless of estimated insurance reimbursement. If you request Loudon Business Solutions to file for reimbursement, there will be a fee of 10% of the reimbursed total to cover the cost of the services.
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Insurance Subscriber Name (if not client)
Insurance Subscriber Birthday (if not client)
Front and Back of Insurance Card*

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Billing Registration Fee
Fee for registering with our billing company, including verification of out-of-network benefits.

$25.00

Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.