I certify that the information on this form is correct to the best of my knowledge. By signing this form, I authorize Larsen Billing Service (LBS) to confirm my primary insurance benefits and authorize Premier Birth Center Chantilly charge me the fee of $25. Once this form has been completed, LBS will begin the process of confirming your benefits and whether we are contracted with your insurance carrier. They will also pursue obtaining pre-authorization and in-network exception (if possible). LBS will send a copy of the insurance snapshot to the email address listed above on the Patient Registration Form and to your provider. Please note that Insurance Snapshot 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. LBS is not responsible for deviations from the insurance coverage described within the Insurance Snapshot form, nor for incorrect information given by health plan representatives. Some insurance companies may be difficult to obtain benefits information from; if the benefits call exceeds two hours, we will contact you for assistance in obtaining a complete Insurance Snapshot. LBS will send the completed Insurance Snapshot form to both the patient and the provider from an email address and system that is appropriately encrypted according to HIPAA/HITECH regulations, 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 the Insurance Snapshot services does not guarantee that my claims will be submitted and does not create a contract for billing services between myself and LBS Larsen Billing Service 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. Larsen Billing Service 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 Larsen Billing Service to any patient seeking Insurance Snapshot services is limited to the cost of the Insurance Snapshot ($25.00) under this agreement. Verifications that are performed at no cost to the patient carry zero liability.