Insurance & Billing | Premier Birth Center Chantilly, VA

Insurance Snapshot

If you are planning to receive care from one of the midwives at Premier Birth Center and intend to use insurance, completion of the insurance snapshot form is required. We charge a $25 fee for our professional billing company to provide a personalized estimate of your out-of-pocket costs, so we can create a tailored payment plan for your care. This estimate is based on their extensive experience with our claims and a review of your insurance benefits through payer portals as needed. This process ensures you have a clear understanding of your financial responsibility prior to beginning care.

Currently, Premier Birth Center Chantilly is in-network with Aetna, Cigna, CareFirst, and United Healthcare. However, some plans or networks under these insurers may not be covered. For this reason, we require all clients to complete the insurance snapshot before initiating care.

If you are covered under a Healthshare plan or are interested in exploring alternative financial options, please contact us at 540.709.1737 ext. 5.

Client Registration Form

Name

Address

Date of Birth required

Estimated Due Date required

Phone

Where do you plan to give birth? (If undecided, check the places of service you may consider) Required

Chantilly Birth Center

Home (with prenatal/postpartum care)

Insurance Information

Primary Insurance
(If you also have secondary insurance, complete a second insurance snapshot)

Insurance ID Number

Insurance Group

Insurance Address/City/State/Zip

Insurance Phone

Plan Name

Effective Date

Insurance Policy Holder Name

Policy Holder Birth Date required

To reduce errors and expedite your snapshot, please upload a picture of the front and back of your insurance card.

Insurance Card Front

Upload File

Upload supported file (Max 15MB)

Insurance Card Back

Upload File

Upload supported file (Max 15MB)

Terms & Conditions

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 $20. 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 ($20.00) under this agreement. Verifications that are performed at no cost to the patient carry zero liability.

I accept terms & conditions

Type your first and last name to electronically sign this form

When Will My Insurance Be In-Network

We are at the mercy of the insurance companies, but we are very diligent on all communication between us, the insurance companies, and Larsen Billing. If you would like to be notified about our insurance progress, you can keep checking this page, send us a message, or contact us at 540.709.1737 ext 3.