Inland Empire Lactation — Insurance Verification
Please complete the form to verify your insurance benefits before your visit. Have your insurance information ready.
Client Information
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Baby's Due Date or Birth Date
*
-
Month
-
Day
Year
Date
Insurance Details
Insurance Company / Plan Name
*
Member ID / Insurance ID Number
*
Group Number
Policyholder Name
*
First Name
Last Name
Policyholder Date of Birth
*
-
Month
-
Day
Year
Date
Service Preferences
Service Interested In
*
Please Select
In-Home Lactation Consultation
Virtual / Telehealth Consultation
Prenatal Lactation Education
Pumping Support Session
Breastfeeding Class
Not Sure — Help Me Decide
Visit Preference
In-Person
Virtual / Telehealth
Either works for me
New or Returning Client
New Client
Returning Client
Insurance Card Uploads and Notes
Upload Insurance Card — Front
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Upload Insurance Card — Back
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Additional Notes or Questions
Submit Verification Request
Should be Empty: