Insurance Verification of Benefits

Please fill in the information to the best of you ability.  Any missing information could result in the delay of your verification.

mm-dd-yyyy
mm-dd-yyyy

date your coverage began
Provider Services #


I certify that the information provided in this form is correct to the best of my knowledge. By signing this form, I authorize Edenway Birth Center, LLC (EBC) to verify my insurance benefits. Once this form has been completed, EBC will begin verifying your benefits. Should an in-network exception be available, we will begin the process for that. We will emailcopy of the verification information to the email address listed above. Please note that the information contained in the VOB does not guarantee coverage at this level. The insurance company has the right to make a final ruling on each claim submitted according to their latest policies and procedures. EBC is not responsible for changes from the insurance coverage presented in the VOB form, nor for incorrect information given by health plan representatives. EBC is not responsible for any breach that may occur due to the verification information being received by an unsecure email address. I understand that the purchase of Verification services does not guarantee that my claims will be submitted or paid at verified amounts.
EBC 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 VOB report. EBCassumes 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 EBC to any patient seeking Verification of Benefits services is limited to the cost of the verification ($20.00).