ANY Insurance Verification

What Happens After You Submit This Form?
Submitting this form allows us to verify your insurance benefits for doula services. Benefit verification does not automatically reserve a doula or guarantee availability.

Doula support is scheduled on a first-come, first-served basis and depends on availability around your estimated due date. To provide consistent, high-quality care, each doula accepts a limited number of births per month.

If in-person birth availability is full, you may still use your prenatal and postpartum visits. Virtual birth support is also available when appropriate.

Once your benefits are verified, you will be notified within approximately 7 business days. At that time, we will move forward with scheduling your initial 90-minute visit with one of our team members.

Insurance Plans We Currently Work With
• Kaiser
• Health Net
• Blue Cross Blue Shield (Medi-Cal only)
• Anthem Blue Cross (Medi-Cal only)

Birthing Persons Name

First NameLast Name

Have you ever changed your name legally?

If you answered YES to a previous name, please share your previous name.

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Your Birth Date

Date

Delivery Location?

Estimated Due Date

Date

Email

example@example.com

Partner or Husbands name (if applicable)

First NameLast Name

Partner Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What Health Plan Do you Have?

Is this plan a Medi-Cal plan?

Insurance Member ID

Is a group ID listed on your insurance card? If YES please list below.

Front Of Card

Back of Card

Do you have a Second Insurance? If YES I will need to obtain a copy of this card as well.

Secondary Insurance Card Upload Front

Secondary Insurance Card Upload Back

Who is the subscriber to the primary health plan?

FRONT If your insurance is under your spouse or parent we will need a copy of their insurance card as well.

Back

Spouse or Parents Name

First NameLast Name

Spouse or Partner DOB

Date

Are you pregnant or postpartum?

How do you identify?

What is your Race Ethnicity?

Have you worked with any other doula during your pregnancy and gave your insurance information to them for billing?

If you answered yes to working with a prior doula during this pregnancy did they use a billing company and bill for services? (Raya Health, Loula, Okra)

Signature