Verification Of Benefits-Kandice Walsh

For all clients completing a verification of benefits for:

Amy Michaelson Ratcliffe, LM, CPM (Resolve Birth Center)
Ashley Bennett, CPM (Staying Home Birth)
Bliss Birth Center
Christa Elizondo, LM, CPM
Cheryl Moore, LM, CPM
Danielle McEntee, CPM
Emily Hovet, LM, CPM
Jennifer Carvallo, APRN, IBCLC, LMT, CNM (Roots Up Midwifery)
Je’Nelle Cook, LM, CPM (Charisma Midwifery)
Joycelyn Romero (3 Sisters Midwifery)
Lisa Rutledge, LM, CPM (Woodlands Midwife)
Nativiti Birth Center
Polly Murdock
Shani VanPatten, LM, CPM (Cypress Midwifery Co)

Members with a secondary insurance will need to submit an additional $40.00 payment to verify the secondary policy. You will need to complete payment first, then complete the form portion of the page.

NOTE: We are unable to process verification of benefits for any Medicaid plans at this time. We recommend finding a provider who accepts Medicaid.

Verification of Benefits – This fee is not related to claims filing (please refer to the pricing page) but is helpful in determining if your policy will reimburse your out of hospital based maternity care.

$40.00

Please allow seven business days for a complete verification of benefits. Once verification of benefits is complete, both you and your Midwife will receive a copy of the verification of benefits. *Please note your verification of benefits may be sent to your SPAM folder. If you believe you have not received your verification of benefits within seven business days of your submission, please check your spam folder.

A quote of benefits and/or authorization does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the

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Thank you for your response. ✨

Expectant Mother’s Name:

Email Address:

Patient Phone Number:

Preferred Midwife:

Home Birth or Birth Center Delivery:

Expectant Mother’s Date of Birth:

Estimated Due Date or Delivery Date:

Member Address (Please include City, State and zip code):

Policy Holder’s Name:

Name of Insurance:

Member ID:

Group Number:

Provider Phone Number (on the back of your insurance card):

Permission to Release-Permission to release protected medical information to a 3rd party (Your Midwife/Birth Center):

Thank you for your response. ✨

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