CBO Midwife Billing Patient Registration Form

Provider name *
First name*
Last name*
Address*
City*
State*
Zip*
Home Phone
Cell Phone
Email*
Social Security*
General Care*

General PracticeMaternity CareWell Woman Care/ GYN
Birthday*

MonthDayYear
Date
Due Date*

MonthDayYear
Date
LMP *

MonthDayYear
Date
Would you like Billing God's Way to verify your benefits?*

YesNo
First Pregnancy?*

YesNo
Place of service*

HomeBirth CenterHospital
Primary Insurance Company*

1
Primary Insurance Company*
Plan Name
Effective Date

MonthDayYear
Date
Insurance ID*
Insurance Group
Insurance Address
City
State
Zip
Insurance Phone*
Insurance Policy Holder Name*
Relationship to Insurance Policy Holder*
Birthday*

MonthDayYear
Date
Sex*

MaleFemale
Social Security*
Employer
Secondary Insurance Company
Plan Name
Effective Date

MonthDayYear
Date
Insurance ID
Insurance Group
Insurance Address
City
State
Zip
Insurance Phone
Insurance Policy Holder Name
Relationship to Insurance Policy Holder
Birthday

MonthDayYear
Date
Sex

MaleFemale
Social Security
Employer
Notes
I certify that the information on this form is correct to the best of my knowledge. By signing this form, I authorize Billing God's Way (BGW) to verify my primary insurance benefits and charge me the fee of $25. I authorize secondary insurance benefits to be verified for an additional fee of $10 if necessary.
I agreeI disagree
Billing God's Way specifically DISCLAIMS LIABILITY FOR INCIDENTAL OR CONSEQUENTIAL DAMAGES and assumes no responsibility or liability for any loss or damage suffered by any person as a result of the use or misuse of any of the information or content included in this Verification of Benefits report. Billing God's Way assumes or undertakes NO LIABILITY for any loss or damage suffered as a result of the use, misuse or reliance on the information and content on the Verification of Benefits report or findings.

In the case of gross negligence or willful misconduct, the liability of Billing God's Way to any patient seeking Verification of Benefits services is limited to the cost of the verification ($25.00) under this agreement. Verifications that are performed at no cost to the patient carry zero liability.
Type a question

I agreeI disagree
Patient Name

First NameLast Name
Date

MonthDayYear
Date
Email

My Products

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Payment Methods