Insurance verification Form Medical Information Release FormFor use of verification of insurance benefits.Client Name(Required) First Last Your Date of Birth(Required) Month Day Year Midwife Name(Required) Estimated Due Date(Required) Month Day Year This form authorizes Birth & Wellness Center of Arlington to release information that includes personal demographics, insurance details, diagnosis and medical records to use as required for insurance purposes. By signing, I understand Birth & Wellness Center of Arlington will be contacting my insurance company on my behalf to assist in processing of claims and allowing my provider to be paid for services rendered.Client Signature(Required)This release will remain in effect until your file is closed.Today's Date(Required) Month Day Year Verification of Benefits InformationName(Required) First Last Date of Birth(Required) Month Day Year Address Street Address City State / Province / Region ZIP / Postal Code Email(Required) Phone(Required)Last Menstrual Period:(Required) Estimated Due Date:(Required) Month Day Year Are you interested in Birth Center or Homebirth? Birth Center Homebirth I'm not sure yet Name of Insurance Company:(Required) Provider Services Phone Number:(Required) Member ID(Required) Group Number(Required) Your Insurance Policy I am the primary insured person I am covered under a family member's insurance policy Insured’s Name (if not you): Insured Person's Address Street Address City State / Province / Region ZIP / Postal Code Insured Person's Date of Birth: Month Day Year Relationship to Insured: Fee(Required) Price: There is a $30 fee for this verification of benefits to be processed. Yes I understand this requirement. Verification is required prior to coming into care. If your due date is in 2025, a new verification will be required in January to determine if there have been any plan changes. The verification fee will be required again at the time of re-verification. Yes I understand this requirement. Total Coupon Credit Card Cardholder Name Card Details
