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 Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / 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
Payment Methods
Debit or Credit Card
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