New Client Information Form

New Client Information Form

New Client Interest and Insurance Review Form
This form is for new clients who are interested in establishing care at NorthPointe Birth Center and/or who would like to find out if their insurance is in-network.

It will ask for some basic information, along with insurance details so we can review your benefits.

Please still complete this form even if you are planning to self-pay. Once submitted, a member of our birth center team will reach out within 2–3 business days to connect with you. You will also receive a free insurance/financial review from our Patient Financial Counselor via email within 2–3 business days.

We’re excited to connect with you!

New Client Interest and Insurance Review Form

NorthPointe Birth Center
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Your Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pregnancy and Birth CareWell-Body CarePreconception CareOther
Estimated Due Date (if known)

MonthDayYear
Date
YesNoOther
If so, what is the name of your provider?
YesNo
Please share any information about yourself that you feel is important. You’re also welcome to include any questions you have about the birth center.

Coverage Type
InsuranceSelf Pay
Insurance Information
YesNo
What is the subscriber's relationship to the client?
Subscriber's Full Name

First NameLast Name
Subscriber Date of Birth
Name of Health Plan
Insurance Policy Number
Group Number
Front of insurance card

Cancelof
Back of insurance card

Cancelof
How did you hear about the birth center?*
How do you prefer to be contacted?
Should be Empty: