Client information form

1
Your name* This field is required.
First Name
Last Name
2
Your email address* This field is required.
example@example.com
3
Your mailing address* This field is required.
Street Address
Street Address Line 2
City
State
ZIP Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Your phone number* This field is required.
Area Code
Phone Number
5
Your date of birth* This field is required.
Date
Year
Month
Day
6
Are you seeking insurance payment or reimbursement for pregnancy-related care?* This field is required.
YESNO
7
What kind of care are you receiving from your midwife?
8
Date of your last menstrual period
Date
Year
Month
Day
9
Your estimated due date
Date
Year
Month
Day
10
Where are you planning to give birth?
Home
Birth center
Hospital
11
Have you previously given birth by Cesarean?
YESNO
12
Your midwife's / birth center's name* This field is required.
13
Your midwife's / birth center's email address
example@example.com
14
Please tell us more about your primary insurance coverage:* This field is required.
Insurance company
ID number
Please Select
Please Select
Yes
No
Is this a Medicaid or Medicaid managed care plan?
15
Subscriber's name* This field is required.
First Name
Last Name
16
Subscriber's date of birth* This field is required.
Date
Year
Month
Day
17
Your relationship to the subscriber:* This field is required.
Self
Spouse
Other
18
Please upload images of the front and back of your insurance card.* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 2.0MB
Cancelof
19
Are you covered by more than one insurance plan?* This field is required.
YESNO
20
Please tell us more about your secondary insurance coverage:
Insurance company
ID number
Please Select
Please Select
Yes
No
Is this a Medicaid or Medicaid managed care plan?
21
Subscriber's name
First Name
Last Name
22
Subscriber's date of birth
Date
Year
Month
Day
23
Your relationship to the subscriber:
Self
Spouse
Other
24
Please upload images of the front and back of your insurance card.
Drag and drop files here
Select files to upload
Max. file size: 2.0MB
Cancelof
25
Are you covered by more than two insurance plans?
YESNO
26
Which services would you like Cohosh to provide?* This field is required.Please select an answer for each of the four rows (you may have to scroll down). For more information about our services, please visit the Services & Fees page of our website: https://cohoshbilling.com/services-and-fees
Yes
No
Verification of benefits
Row 0, Column 0
Row 0, Column 1
Gap exception request/appeal
Row 1, Column 0
Row 1, Column 1
Claim preparation & submission
Row 2, Column 0
Row 2, Column 1
FSA, HSA, or HRA invoice preparation & submission
Row 3, Column 0
Row 3, Column 1
Verification of benefits
Gap exception request/appeal
Claim preparation & submission
FSA, HSA, or HRA invoice preparation & submission
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
1 of 4
27
Please click the "NEXT" button to review our service agreement and download it if you'd like a copy.
28
After you've reviewed and downloaded the service agreement, click the "NEXT" button to electronically sign the agreement.
29
Service agreement signature* This field is required.AUTHORIZATION TO RELEASE INFORMATION I hereby authorize my midwife and/or birth center and Cohosh to: (1) process insurance claims generated in the course of examination or treatment; and (2) release any information necessary to my health insurance plan (or its administrator) regarding care I have received. I understand this information is protected by law and will be kept confidential. VERIFICATION OF BENEFITS CONSENT The information I have provided to Cohosh is true to the best of my knowledge. I acknowledge that a verbal quote of benefits from my health insurance provider is not a guarantee of payment, which is determined according to the provisions of my health insurance coverage at the time services are rendered. I understand that I am responsible for payment of applicable deductible, coinsurance, copayment, and premium amounts, as well as any charges not covered by my health insurance. I understand that the verification of benefits report is provided as a financial planning tool, and that the information contained therein is not considered binding by my health insurance provider, midwife, or birth center. I understand that Cohosh is not responsible for incorrect information provided by the representatives of my health insurance provider. I acknowledge that Cohosh specifically disclaims liability for incidental or consequential damages and assumes or undertakes no responsibility or liability for any loss or damage suffered by any person as a result of the use or misuse of information included in the verification of benefits report. I acknowledge that in the case of gross negligence or willful misconduct, the liability of Cohosh to any client seeking verification of benefits services is limited to the cost of verification of benefits ($45.00) under this agreement. APPEAL, CLAIM, AND INVOICE PREPARATION AND SUBMISSION CONSENT I authorize, to the full extent permissible under law and under any applicable health insurance policy and/or healthcare benefit plan, Cohosh to act as my authorized representative. As such, Cohosh is granted: (1) the right and ability to submit claims to the health insurance plan (or its administrator) listed on my current insurance card of which I have provided a copy; (2) the right and ability to act on my behalf in connection with any claim, right, or cause in action that I may have under such health insurance policy and/or healthcare benefit plan; and (3) the right and ability to act on my behalf to pursue such claim, right, or cause of action in connection with said health insurance policy and/or healthcare benefit plan, including, but not limited to, the right to act on my behalf in respect to a benefit plan governed by the provisions of ERISA as provided in 29 C.F.R. §2560.503-1(b)(4), with respect to any healthcare expense incurred as a result of the services I received from my midwife and/or birth center, to the extent permissible under the law, and to claim on my behalf such benefits, claims, reimbursements, and other applicable remedies, including fines. I acknowledge that submission of an appeal, claim, or invoice is not a guarantee of payment, which is determined according to the provisions of my health insurance coverage at the time services are rendered. I understand that I am responsible for payment of applicable deductible, coinsurance, copayment, and premium amounts, as well as any charges not covered by my health insurance. I authorize the irrevocable assignment and transfer to my midwife and/or birth center of all applicable health insurance benefits to which I am entitled and/or my dependents are entitled. I authorize my health insurance plan (or its administrator) to make payments directly to my midwife and/or birth center. I understand that Cohosh specifically disclaims liability for incidental or consequential damages and assumes or undertakes no responsibility or liability for any loss or damage suffered by any person as a result of the adjudication of claims submitted by Cohosh on my behalf. I acknowledge that in the case of gross negligence or willful misconduct, the liability of Cohosh to any client seeking claim preparation and submission services is limited to the cost of claim preparation and submission ($90.00 per claim) under this agreement. This consent will remain in effect until revoked by me in writing. A photocopy or electronic transmission of this consent shall be as effective and valid as the original.
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