Verification of benefits

Please make sure that your policy is currently in effect. We cannot verify benefits for past or future policies. After your Verification of Benefits has been submitted, your browser will be redirected so you may add this service to your cart. Please add the service to your cart and complete checkout so we may begin verifying your benefits. The cost is $35 for your primary insurance. If you have a secondary insurance, please list it in the note section below. It is an additional $20 for your secondary insurance. Please don’t forget to add this additional service to your cart. After we have received your payment and verified your benefits, we will send you a report via email. This report will include your rate of coverage, deductible information, and whether or not any specific services or facilities are covered. Please note that it may take up to 3 business days for us to send you this report.

PROVIDER INFORMATION

PLEASE ENTER YOUR PROVIDER'S NAME

First Name

Last Name

PROVIDER NPI NUMBER

PLEASE ENTER YOUR PROVIDER'S NATIONAL PROVIDER IDENTIFIER:

PATIENT INFORMATION

First Name

Last Name

ADDRESS

PLEASE ENTER YOUR ADDRESS BELOW:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

PHONE NUMBER

PLEASE ENTER YOUR PHONE NUMBER BELOW:

(###)

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EMAIL ADDRESS:

PLEASE ENTER YOUR EMAIL ADDRESS BELOW:

TYPE OF SERVICE

DATE OF BIRTH

PLEASE ENTER YOUR DATE OF BIRTH BELOW:

YYYY

DUE DATE

YYYY

PLACE OF SERVICE

HOME

BIRTH CENTER

INSURANCE INFORMATION

NAME OF PRIMARY INSURANCE COMPANY:

INSURANCE ID

PLEASE ENTER THE MEMBER ID LOCATED ON THE FRONT OF YOUR INSURANCE CARD:

INSURANCE GROUP NUMBER

PLEASE ENTER THE GROUP NUMBER LOCATED ON THE FRONT OF YOUR INSURANCE CARD:

INSURANCE PHONE NUMBER

PLEASE ENTER THE PROVIDER/MEMBER SERVICES NUMBER LOCATED ON THE BACK OF YOUR INSURANCE CARD:

(###)

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RELATIONSHIP TO INSURANCE POLICY HOLDER

NOTES

PLEASE ENTER YOUR SECONDARY INSURANCE INFORMATION BELOW AND ANY ADDITIONAL INFORMATION YOU THINK WILL HELP PROCESS YOUR REQUEST:

AGREEMENT

I certify that the information on this form is correct to the best of my knowledge. By signing this form, I authorize True Healthcare Billing (THB) to verify my primary insurance benefits and charge me the fee of $35. I authorize secondary insurance benefits to be verified for an additional fee of $20, if necessary. Once this form has been submitted, your browser will be redirected so you may add this service to your cart. Once the payment has been received, we will begin the process of verifying your benefits. We will send a copy of the verification information to the email address listed above. Please note: Verification is not confirmation that the insurance company will pay what is stated when verifications were obtained. The insurance company has the right to make a final ruling on each claim submitted according to their latest policies and procedures. THB is not responsible for deviations from the insurance coverage described within the VOB form, nor for incorrect information given by health plan representatives. Some insurance companies may be difficult to obtain benefits from; if the benefits call exceeds two hours, we will contact you for assistance in obtaining a complete Verification of Benefits. THB will send the completed Verification form to the patient, but is not responsible for any breach that may occur due to the message being received by an unsecure email address. I understand that the purchase of Verification services does not guarantee that my claims will be submitted and does not create a contract for billing services between myself and THB.

I agree to the terms as listed above

True Healthcare Billing specifically DISCLAIMS LIABILITY FOR INCIDENTAL OR CONSEQUENTIAL DAMAGES and assumes no responsibility or liability for any loss or damage suffered by any person as a result of the use or misuse of any of the information or content included in this Verification of Benefits report. True Healthcare Billing assumes or undertakes NO LIABILITY for any loss or damage suffered as a result of the use, misuse or reliance on the information and content on the Verification of Benefits report or findings. In the case of gross negligence or willful misconduct, the liability of True Healthcare Billing to any patient seeking Verification of Benefits services is limited to the cost of the verification ($35.00) under this agreement. Verifications that are performed at no cost to the patient carry zero liability.

I agree to the conditions as listed above

PATIENT NAME

First Name

Last Name

TODAY'S DATE

YYYY

EMAIL ADDRESS