Nurture The Star Doula Services

Nurture The Star Doula Services

Insurance contracting and billing
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Your Date of Birth
Preferred method of Communication
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doula Offerings
Birth, Postpartum, Full Spectrum, childbirth ed... etc.
How long have you been a doula for?
If birth doula, what does your package include? What is your current rate?
What is your current postpartum rate?
What areas do you service?
Languages you are fluent in and can offer services in?
Are you currently contracted with Insurance? If so, which ones?
CPR card

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HIPPA training

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Doula Certification

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Proof of Professional Liability Insurance

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NPI number
Photo ID

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Do you need help with any of the credentials? If so, which ones?
NPI, Hippa, etc.
Do you have past or current clients who have insurance? If so, which insurance and are you contracted?
How many clients a year do you serve?
How do you prefer to be paid?
Zelle, Venmo, Direct Bank Transfer
What are your professional strengths and assets? Would you like to contribute to our monthly meetings?
What are your expectations for Nurture the Star Doula / Billing Service?
Are you okay with receiving a 1099 for taxes?

YesNo
Are you okay with committing to 1 year of services with me?

YesNo
Upload EOBs here if you are currently having trouble getting reimbursed.

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AGREEMENT/REMINDERS:

I understand that all information I entered in this form will be considered strictly confidential.

The data gathered from this form will only be used as a basis for the type of billing service the client will need.
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