VERIFICATION OF BENEFITS
Please make sure that your policy is currently in effect. We cannot verify benefits for past or future policies. We also do not verify benefits for any government-sponsored insurance plan. If you have a secondary insurance, please complete a separate form. After we have verified your benefits, we will send you a report via email. The report will include your deductible information, coinsurance information and whether or not any specific services or facilities are covered. Please note that it may take up to 5 business days for us to send you this report.
PROVIDER INFORMATION
The information in this section is about the person providing the services.
VOB Code
*
Please ask your provider for their VOB code. It is required to complete this form.
Provider Name
*
This field will self-populate after you enter your Provider VOB Code.
PATIENT INFORMATION
The information in this section is about the person receiving the services.
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email
*
example@example.com
Type of Service
*
Please Select
Maternity Care
Well-Woman Care
Other
Place of Service
*
Please Select
Birth Center
Home
Office
If pregnant, where do you plan to deliver?
Date of Service
*
-
Month
-
Day
Year
Expectant mothers, please enter due date.
INSURANCE INFORMATION
The information in this section is about your primary insurance company.
Name of Insurance Company
*
Insurance ID
*
Please be sure to include the prefix
Insurance Group Number
*
Insurance Phone Number
*
Format: (000) 000-0000.
Relationship to insurance policy holder
*
Please Select
Self
Spouse
Child
Other
Insurance Policy Holder
If you are not the insurance policy holder, please complete the information below about the person who holds the insurance policy.
Insurance Policy Holder Name
*
First Name
Last Name
Insurance Policy Holder Date of Birth
*
-
Month
-
Day
Year
Date
Front of Insurance Card
*
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Back of Insurance Card
*
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Cancel
of
I agree to the terms as listed below
*
I certify that the information provided on this form is for a commercial health insurance plan and not for a government insurance program.
I certify that the information on this form is correct to the best of my knowledge. By signing this form, I authorize True Healthcare Billing (THB) to verify my primary insurance benefits. I authorize secondary insurance benefits to be verified, if necessary.
I understand that my provider must be enrolled in the Advanced Service with THB to submit this form, at no cost. If my provider is not on the Advanced Service with THB, additional information may be required and I will be responsible to pay $35.00 for each verification of benefits. I understand that if I am required to pay for the verification of benefits, my benefits will not be verified until the payment has been made, in full.
Verification is not confirmation that the insurance company will pay what is stated when verifications were obtained. The insurance company has the right to make a final ruling on each claim submitted according to their latest policies and procedures. THB is not responsible for deviations from the insurance coverage described within the VOB form, nor for incorrect information given by health plan representatives. Some insurance companies may be difficult to obtain benefits from; if the benefits call exceeds two hours, we will contact you for assistance in obtaining a complete Verification of Benefits. THB will send the completed Verification Form to the email address provided on this form, but is not responsible for any breach that may occur due to the message being received by an unsecure email address. I understand that the submission of this form does not guarantee that claims will be submitted and does not create a contract for billing services between myself and THB.
True Healthcare Billing 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. True Healthcare Billing 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 True Healthcare Billing to any person seeking Verification of Benefits services is limited to the cost of the verification. Verifications that are performed at no cost to the patient carry zero liability.
Patient Signature
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
Submit
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