Billing Service Inquiry

Billing Service Inquiry

This form is for people who are working with/considering working with a Midwife on our list and would like more information about our billing services.
Name*

First NameLast Name
Email*
example@example.com
Midwife Name*
If your Midwife works with us but is not listed, please select 'Other'.
The Billing options for your Midwife are limited to Verification of Benefits and Superbills. We will be sending you an email with information about the billing process, but please keep in mind you will only have access to these two options.
Midwife Not Listed

We do not offer billing services for Midwives who are not working with us. If your Midwife is not listed, but told you she works with us, please select 'Other'. If your Midwife is not listed and does not work with us we cannot process any orders for you at this time. You are welcome to give your Midwife our website.
Should be Empty:

Midwife Not Listed