Please fill out the form below in its entirety in order for Essential Maternity Billing to verify your maternity coverage benefits. The fee for this service is a one-time fee of $25 (or $40 if you are enrolled in two insurance plans; please see "Services & Fees" page) and includes your verification of benefits and one request for a Gap Exception and/or prior authorization as needed.
PLEASE NOTE: If you would like us to submit one or more formal appeals for any denied Gap Exceptions, the fee will be an additional $15 per appeal.
***Important*** We will also need a copy of the front and back of your health insurance card in order to process your benefits request and any claims submitted in the future. You can upload a scanned copy of your card using the file uploader at the bottom of this form, or you may fax it to us at our fax number: 904-212-0416. If you don't have a scanner, a quick and easy way to get a copy of your card is to take a photo with your Smart Phone.
Within one business day of receiving this completed form, Essential Maternity Billing will email you a detailed invoice with instructions for submitting payment (please be sure to list a valid email address).
Please allow 5 to 7 business days to process your Verification of Benefits (VOB) request after we receive your payment.
You are welcome to contact us during regular office hours at (904) 638-5278 if you have any questions relating to this form.
If you would rather fill-out a paper version of this form, please CLICK HERE
to download the form, which can be filled out electronically or manually, saved/printed, and faxed or emailed to our office. Thank you.