Explanation of Benefits Request
This form is to submit a request for help understanding statements your insurance company has sent you. Please upload ALL PAGES of statements.
Not for claim follow up
This form is not to request claim follow up actions. If you need us to follow up with your insurance on a claim, please use the Claim Follow Up request form on our website.
Name
*
First Name
Last Name
Email
*
example@example.com
Midwife
Please Select
Alison Peralta (Trillium Midwifery, WI),
Angela Boisen (Midwife Angie),
Angela Guzzardo (Gennisi),
Beth Connors (Family Focused Midwifery),
Beth Karberg (Turtle Creek Midwifery),
Beth Kratky (123 Midwifery),
Brittany Coffman (Aglow Midwifery),
Brittany Kurtzhals (Gennisi),
Chelsey Isaacson (Gennisi),
Christina Reynolds (In the Beginning),
Connie Lambeth (Pax&Lux),
Courtney Smith (CAS Midwifery),
Crystal Komp (Health Inspired),
Deanna Moore (A Little Moore Midwifery),
Eliza Higgins (Trillium Midwifery, WI),
Erica Boland (Coulee Health),
Fiona George (Gennisi),
Jamie Huberty-Koerner (Solstice),
Jessica Siczkowycz (7 Birds Midwifery),
Jessie Heppner (Gennisi),
Joey Larson (Birthing Miracles),
Katie Breitenmoser (Windy Hill),
Kelsey Pendleton (Gennisi),
Korina Bauer (In the Beginning),
Kova Brown (Baby Love Midwife Services),
Mandy Gloyeske (Little Hands Midwifery),
Mary Denise Doerr (Open Door Midwifery),
Michelle Disney (Aglow Midwifery),
Miranda Overland (Lake Country Midwife),
Rachel Cipryk,
Raquel Shoemaker (Blissful Midwifery),
Tabitha Kropf (Trillium, WI),
Tamara Wills (Blessed Beginnings),
Terri Fischer (Paradigm),
Tjaden Potter (Birthing Traditions),
Valerie Atkinson,
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Additional comments
Please let us know any specific questions or concerns you have about the statements. Also include any information you may have received through insurance portals or phone calls with insurance. This will help us be thorough in the clarification we provide. Thank you!
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