Hours: M-F 9am-5pm EST
Phone: (904) 638-5278
Fax: (904) 212-0416

Verification of Benefits

Maternity Patients:

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.

Patient Information
Policyholder Information
Insurance Information
If yes, please complete an additional Verification of Benefits form listing the details of the secondary insurance plan. You will then receive an invoice for $40, which is the fee for verifying the benefits of two insurance plans.
Midwife or Other Healthcare Provider's Information
You must select 'Yes' to proceed.