Benefits Form for Members With Midwives

EXPRESS CLAIMS

Verification of Insurance Benefits Form

Our verification service includes: Personally calling your insurance company and verifying your benefits, obtaining any authorizations or referrals. We will request in-network coverage for out of network providers when available, if the exception is granted, the services will be reimbursed at the in-network level. Our fee for this service is $25

MEMBER INFORMATION
Name*
FirstLast
Today's Date*
Address*
Street AddressAddress Line 2CityStateZip Code
Phone*
Email*
Marital Status
Birthdate*
Month/Day/Year
ex: 05/27/1974
First Time Pregnancy?*
- Yes
- No
Due Date*
Month/Day/Year
ex: 05/27/2010
Date of Last Menstrual Period (LMP)*
Month/Day/Year
ex: 05/27/2010
Desired Place of Birth Home or Birth Center*
INSURANCE INFORMATION
Primary Insurance Company*
Name of Plan
Insurance Company Address
Street AddressAddress Line 2CityStateZip Code
Insurance Company Phone*
Subscriber's Name*
FirstLast
Subscribers Date of Birth (DOB)*
Month/Day/Year
ex: 05/27/1973
Subscriber's Social Security Number
ID Number on the Card*
Group Number on the Card
Employer's Name if Insurance is Through Employer
Relationship to Subscriber
If Relationship is "Other", Please Specify
MIDWIFE INFORMATION
Name of Chosen Midwife*
FirstLast
Address*
Street AddressAddress Line 2CityStateZip Code
Midwife's Phone Number*
Midwife's Email
Would you like us to foward your benefits information to your midwife?*
- Yes
- No
Authorization*
- I Agree
"I have read the privacy policy and agree to the terms and conditions of EXPRESS CLAIMS (http://expressclaims.org)."

You must check "I Agree" before you can submit your information.

About Us

The company was founded in 1998 by Caroline Silva. With years of medical billing experience and management already under her belt she was looking to start a home based business so she could be a stay at home working mother.

When Caroline started the company she provided services for Alternative specialties, Acupuncture, Massage Therapy and Chiropractic care...

Learn More...
Contact Us

Please use the following information to contact Express Claims.

Phone: (239) 649-4070

FAX: (239) 403-8122

Email: expressclaims@embarqmail.com

or alternatively CLICK ON THE CONTACT US image below to tell us about your inquery.
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EXPRESS CLAIMS

Verification of Insurance Benefits Form

MEMBER INFORMATION

INSURANCE INFORMATION

MIDWIFE INFORMATION

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