Benefits Form for Members Without Midwives

EXPRESS CLAIMS

Verification of Insurance Benefits Form

Our verification service includes: Personally calling your insurance company and verifying your benefits.

If you have not chosen a midwife yet, any authorizations, referrals, network exceptions can not be obtained until this information is provided. This service is useful if you are thinking about having children and would like to see what benefits they would qualify for.

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
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
Relationship to Subscriber
If Relationship is "Other", Please Specify
Verification of Benefits Service Charge*
Price: $25.00
Your verification is very important to us. You will be redirected to PayPal over a secure server to make payment & complete your order.
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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Verification of Insurance Benefits Form

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