Un•tied Registration Form

This is the registration form for working with Dr. Bower at Untied for Lip and Tongue Release. Blossom will be working with Dr. Bower to ensure your information is transferred successfully and safely for your consult. You should be contacted within 2-3 business days.

If you do not hear from our staff at Blossom after 2-3 business days, please contact the office at (602) 256-7766 or email through our contact form.

To receive the best care possible, please complete this form in its entirety.

Today's Date *

Midwife/Physician/Birth Center *

Mother's Full Name *

Mother's Date of Birth *

Baby's Full Name *

Baby's Date of Birth

Baby's Gender *

Mother's Email *

Mother's Street Address *

Mother's City, State, Zip Code *

Mother's Primary Phone # *

Mother's Secondary Phone #

Primary Insurance Subscriber Name *

Primary Insurance Subscriber Date of Birth *

Primary Insurance Name/Company *

Primary Insurance Group Number *

Primary Insurance ID Number *

Primary Insurance Claims Street Address *

Primary Insurance Claims City, State, Zip Code *

Primary Insurance Phone # *

Primary Insurance Policy Effective Date *

Additional Notes and/or Questions

Dental Insurance Name/Company

Dental Insurance Group Number

Dental Insurance ID Number

Dental Insurance Claims Street Address

Dental Insurance Claims City, State, Zip Code

Dental Insurance Phone #

Dental Insurance Policy Effective Date

Insurance Card Upload *

Click or drag files to this area to upload. You can upload up to 2 files.

Please upload a photo of the front and back of your current insurance cards. If you do not have a file to upload, please ignore.

View Disclaimer *

I have read and understood the disclaimer.

FMBS does not guarantee reimbursement. FMBS does guarantee that all efforts will be exhausted to ensure your claim was processed at its highest level of benefit.

Your benefits are decided by your employer and the Information obtained by FMBS is provided by contacting your plan’s provider relation department and are details of your plan benefits.

Benefit Verifications, Patient Responsibility Amounts, and Authorization are not a guarantee of payment. Patient Responsibility provided is an estimate of cost and does not replace any contracts or amounts requested by your provider.

Verification provided by Favored Medical Billing is an estimate. The verification provided will work in one of two ways with your provider of care.

Claim Disclaimer

Claim submission is not a guarantee of reimbursement. Reimbursement is subject to your specific plan benefit and the network status of your provide. FMBS does NOT guarantee NOR control the amount paid by said plan insurance provider. FMBS does guarantee that we will exhaust all option to ensure that submitted claims are properly processed.

Your chosen provider may be considered an out of network provider. For clients that hold HMO policies, reimbursement will not be obtained, as HMO policies do not support out of network providers.

Billed Charge Amount: Due to auditing regulations, FMBS, as a billing company, is required to attain a set billing schedule based on national rates. These rates may differ from the provider's charging schedule FMBS represent.

FMBS billing schedule or billed charges submitted to your insurance payer does NOT mean:

* Provider Maternity Care base rate begins at $8,700.00. If additional services such as labor time, lactation, etc. is provided, this will increase the amount.

* Provider Infant Care base rate begins at $890.00 for initial care provided at birth, If other care is provided, it will increase the bill amount.

* Facility Birth Room is billed at $9,800.00 per day for mother and $9,400.00 per day for infant.

* Outpatient services performed at the facility such as IV treatment / Pap / ultrasounds / IUD placements billed at $5,000.00 to $6,000.00

* That additional monies outside of what has been discussed and agreed upon with your provider are due.

Additional monies will NOT be due to your insurance company.

To calculate billed charge amounts, FMBS use Medicare rates times 400%

Provider
Mother Global Maternity
59400 - $8,700.00
59426 & 59425 - $4,000.00
** the above are base rate charges and does NOT include med, additional time, etc…

Infant initial care
99460/99464 - $860.00
** the above are base rate charges and does NOT include med, additional time, etc…

Facility
Mother Facility - $9,800.00
Infant Facility - $9,400.00
Education & Hearing - $1,000.00
IUD & other Outpt - $9,600.00
Ultrasounds - $3,000.00

Submitting Claims
Based on the limited access FMBS has to medical records prior to billing, claims will be submitted per the superbill provided, outside of minimum coding adjustment within the realm of its AAPC certification and malpractice coverage. In the event the superbill is submitted without the above requirements or in a manner that will hinder proper claim processing/reimbursement/auditing, the superbill will be sent back with a request to resubmit a new claim and deleted from the FMBS system. FMBS will no longer be able to accept email/text corrections of previous submitted claims. Thank you in advance for your cooperation.

Authorization
Authorizations and Gap Requests take a minimum of 21 business days to receive a response from your insurance plan. Please make sure you have allotted the correct amount time for auth submission, response and appeal.

Regular Office Visit Care does NOT require verification. Please contact your provider for Office Visit benefits.

Authorizations are not a guarantee of claim payment. Claim submission is not a guarantee of reimbursement depending on your plan the claim may be processed to your plan deductible and out of pocket. Your benefits are decided by your employer the information I obtain is your already plan benefit.

**Authorizations are not a guarantee of claim payment. ** Claim submission is not a guarantee of reimbursement depending on your plan the claim may be processed to your plan deductible and out of pocket. **Your benefits are decided by your employer the information I obtain is your already plan benefit.

*Authorizations and Gap Requests take a minimum of 21 business days to receive a response from your insurance plan. Please make sure you have allotted the correct amount time for auth submission, response and appeal.

***Regular Office Visit Care does NOT require verification. Please contact your provider for Office Visit benefits.

Comment

Un•tied Registration Form

Claim Disclaimer

Mahlaima and Alex