Complete the form below and I will contact you about my VOB (verification of benefits) and/or Superbill services.

Verification of Benefits: $40.00

A call is made for each verification of benefits. The right questions are asked to obtain the information needed for your unique birth plan may it be at a birth center or at home.

midwifery clients:

Superbill: $100
This is an itemized statement for you to provide to your insurance that includes CPT, diagnosis codes and the pertinent information required.

Expectant Mom's Name

First Name

Last Name

Expectant mom's date of birth

MM

DD

YYYY

Phone

(###)

###

####

Email

Please check your spam/junk folder if you do not receive a response within 24-48 hours

Midwife's Name:

First Name

Last Name

Practice / Birth Center Name:

If name is same as Midwife, put "same"

Midwife/Birth Center's location

City/State

What insurance plan do you have?

Example: BCBS, UHC, CIGNA, MEDICAID, etc.

Insurance member ID

Insurance group number

Insurance provider number

Number on the back of your card

(###)

###

####

Your estimated due date (or date you delivered)

MM

DD

YYYY

Inquiring about

Verification of Benefits

Superbill / Invoice needed

"Other" Please add response in comments

Message/Comments